Special Thematic Section on " Aging and Health in Different Sociocultural Contexts " How Do Formal Caregivers Experience the Sexuality of Older Adults ? Beliefs and Attitudes Towards Older Adults ’ Sexuality

Aim: The way caregivers experience the sexuality of older adults has implications to their identity and sexual manifestations. There are few studies that focus on the meaning of caring of older adults, taking into account their sexuality. This study aims to explore the experiences of formal caregivers (FC) towards sexuality among older adults, and to obtain a description of their experiences. Method: Complete data were available from six caregivers working in a nursing home. We used a sociodemographic questionnaire and topic interview guide. The data was subjected to content analysis. Results: The most prevalent response of the interviewed participants for ‘beliefs about the interest in sexuality’ was ‘health limitations despite the desire’, for ‘observed behaviours related to sexual expression’ was ‘masturbation’, and for ‘reactions/behaviours due to the demonstration of sexual expression was ‘using humour”. Conclusion: Future educational and intervention programs in the institution should take into account our findings to improve their efficacy on discussing these issues and to ultimately promote sexual wellbeing.

Population aging is progressing rapidly in both industrialized and developing countries.Between 2015 and 2030, the number of people in the world aged 60 years or over is estimated to grow by 56%, and by 2050, the global population of older persons is predicted to double its size.In fact, projections indicate that in 2050 the oldest-old will triple in number since 2015 (United Nations, Department of Economic and Social Affairs, Population Division, 2015).Therefore, studying issues affecting older people is pertinent (Taylor & Gosney, 2011).Freud (2009) in his book Three Essays on the Theory of Sexuality, written in 1905, advocates the manifestation of sexuality at much earlier stages of development: it has been present in the child since birth.On the other hand, Weeks (1985) states that sexuality refers to words, images, ritual and fantasies about the body.More recently, sexuality is conceptualized as a basic drive and a natural expression of a human need that is integral to quality of life (World Health Organization, 2016) and an important component of well-being throughout the life span (Bentrott & Margrett, 2011).
The emerging view in the literature suggests that interest in sex does not necessarily diminish with entry to a nursing home (Elias & Ryan, 2011).There is evidence that nursing home patients are still interested in sex and engaging in sexual activities, much like their community dwelling counterparts (Schwartz, Diefendorf, & McGlynn-Wright, 2014;Spector, Carey, & Steinberg, 1996).Sexuality also remains important for many older people living in long term care facilities, such as nursing homes (Hubbard, Downs, & Tester, 2003), where a range of sexual behaviours have been reported by residents including holding hands, talking dirty, masturbation, intercourse, watching or reading sexually explicit material, and the prostitution (Nay, 2004, as cited by Bauer, McAuliffe, Nay, & Chenco, 2013).However, admission to a nursing home can bring implications such as loss of personal freedom, especially when it comes to sexual fulfilment (Roach, 2004).
There are several factors that can affect sexual manifestation in older adults, such as the lack of privacy, the negative attitudes of FCs, lack of a sexual partner, cognitive dysfunctions, health problems and physical disabilities, amongst which the main barriers appear to be the attitudes of the FC and the lack of privacy (Parker, 2007;Tarzia, Bauer, Fetherstonhaugh, & Nay, 2013).
Research has shown that FCs play a central role in the care of institutionalized older adults and indirectly determine beliefs and actions and which sexual acts are tolerated (Lyder, 1994).The attitudes and knowledge of FCs regarding the sexuality of older adult residents has a direct impact on their sexual expression (Eddy, 1986;Walker & Harrington, 2002), something which is important when considering that in nursing homes, it has been shown that FCs reported confusion, embarrassment, anger, denial, and helplessness when confronted with the fact that old people were involved in behaviour such as kissing, hugging, and holding hands (Gastmans, 2014).
Current literature shows evidence for an emergent consensus amongst health care professionals that addressing sexual issues ought to be part of the holistic care of patients (Higgins, Barker, & Begley, 2006).
However, despite a growing recognition of the importance of this issue, studies on the sexual expression of older people living in nursing homes are scarce, thus making it a less investigated topic (Gastmans, 2014;Elias & Ryan, 2011).More specifically, little is known about how FCs perceive and manage later life sexual health problems (Bentrott & Margrett, 2011;Gott, Hinchliff, & Galena, 2004;Roach, 2004), highlighting a need to develop the evidence base which would support the inclusion of sexual health and policy guidelines in the education and training of residential care home staff (McAuliffe, Bauer, & Nay, 2007).Moreover, with respects to the meaning of caring for older adults and their sexuality, most studies have focused only on perceptions and attitudes of FCs, and do not emphasis on FC's beliefs.Thus, using a qualitative method we can be have access to the varying perspectives and experiences of FCs, their beliefs and attitudes, specifically.In this context, this study aims to explore the perspectives of FCs towards the sexuality of older adults, and to obtain a description of their experiences.

Method Participants
The total sample included six FCs.Participants aged 24 to 61 years (M = 44.83;SD = 14.20), and a large majority being women (83.3%).One inclusion criterion was taken into account: that the participant was in daily contact with older adults.Most of the participants were nursing home assistants (83.3%), and one participant was a nursing home manager.66.7% were in a relationship or married whilst the remaining were single.66.7% had geriatric qualifications whilst two participants had no such qualifications.FCs performed their functions in the institution for time periods ranging from two weeks to 23 years, with 2 to 23 years of experience working with older adults in nursing homes or in home care (see Table 1).The sampling of participants was based on the availability of participants and they were recruited in one nursing home for older adults in the Lisbon area.
Participants were informed about the study by the nursing home manager and all those invited by the researcher accepted to participate.Once informed consent had been received, The American Psychological Association's standards on the ethical treatment of participants were followed.

Data Collection
Semi-structured interviews based on an interview guide were conducted in a room provided by the nursing home's manager.Subjects who agreed to participate in the study were asked to read and sign an informed consent stating that participation is voluntary, and that they may withdraw at any time without any consequences or damages.They have also been notified that the confidentiality of your data and anonymity will be guaranteed.After this procedure was performed the interviews.Each interview was performed individually and began with a set of straightforward background questions to find out about their age, marital status, academic qualifications, institutional function, time exercising this function, and which contexts they worked in with older adults.Then, several questions related to how FCs experience the sexuality of older adults were asked.
Participants were asked about their beliefs about the interest in sexuality through the question "Do you consider that old people are interested in their sexuality?".Also, FCs were questioned about the observed behaviors related to sexual expression through the question "How do old people express their sexuality, given your experience and background?".To evaluate the FCs' reactions/ behaviors due to demonstration of sexual expression was used the following questions: "Can you describe situations in which you had to deal with the sexuality of the old people in the institution?","How do you feel when it happens?" and " who had no previous relationship with the participants.The interviews lasted an average of 50 minutes; the shortest was 40 minutes and the longest was 62 minutes.

Data Analysis
Data was analyzed using content analysis.The following procedures were carried out: a) development of major emergent categories, which were mutually exclusive, that reflected the six interviews; b) creation of a list of coding cues; c) analysis of verbatim quotes and best fit descriptions for a given emergent category d) definition of sub-categories, within and across the narratives, while preserving the principle of homogeneity of the category and e) derivation of major emergent categories until the point of theoretical saturation was reached (Bardin, 2007).Our structure of sub-categories and categories was then subjected to an external review and critical feedback was obtained from other reviewers.An independent analysis of the six interviews was performed by a jury (two psychologists) and a final group co-resolution.

Content Analysis of the Emergent Categories
Content analysis was performed for the following themes: 1) 'beliefs about the interest in sexuality', 2) 'observed behaviours related to sexual expression', and 3) 'reactions/behaviours due to the demonstration of sexual expression'.For each emergent category resulting content analysis was calculated its frequency (Table 2).

Beliefs About the Interest in Sexuality
Findings designated a total of nine categories for 'beliefs about the interest in sexuality': 'health limitations despite the desire', 'gender differences', 'interest in sexuality', 'no interest in sexuality', 'not the same ability of expressing sexually', 'need for expressing sexually', 'widowers having less interest in sex', 'older adults reserved about sexuality', 'older adults have more sexual experience'.
Health limitations despite the desire -Participants verbalized that older adults are still interested in sexual activity despite their health conditions.Some participants recognized that physical illnesses can affect sexual desire, while others mention mental illness as limiting.
"Not that they inhibit ... the body does not allow it."(P1) "The way the old people express themselves sexually depends on their state of health."(P2) Gender differences -Participants reported that for older men it is more difficult to accept their sexual dysfunctions and that older women are less interested in sexual activities.The female participants recognize it because of the stereotype that men are the only responsible for providing pleasure to women, and women just receive it.Older adults reserved about sexuality -Participants recognise that older adults do not like to show what they feel, that this is implicit in his own personality.
"Their sexuality still flows, but they have a certain care… not to show it."(P2) "They are sometimes ashamed to talk about these subjects and do not want to share it with us... but then when they talk, we see that they like to talk about it."(P6) Beliefs and Attitudes Towards Older Adults' Sexuality Older adults have more sexual experience -Participants reported that older adults have more sexual experience than younger people.
"An elderly has more experience... he knows how to play, he knows better how to give pleasure to a woman."(P2) "They have a lot more passion than a 20-year-old.They know how to give pleasure."(P2)

Observed Behaviours Related to Sexual Expression
Findings designated a total of four categories for 'observed behaviours related to sexual expression': 'masturbation', 'touching', 'erections', 'flirting', and 'none'.
Masturbation -Participants verbalized that they saw old people masturbating.
"I caught a man in the bathroom masturbating".( P6) "Another case of a gentleman, for example, that he masturbates.Sometimes he would masturbate even in the bathroom, but sometimes it was in bed." (P2) Touching -Participants verbalized that they saw older people touching each other.
"The old man sought to touch the old lady's breasts."(P3) "There was a man who took advantage ... went to the ladies' rooms and touched their breasts."(P5) Erections -Participants reported that they observed old man's erections.
"When I barely touched him, his penis erected automatically."(P3) "For example, Mr. X, when we showered him, he always had an erection."(P2) Flirting -Participants recognised that watched sexual dialogues between old adults.
"These games are like: "You still have a lot to give! Look that ass!"." "Some get into each other and even make loving compliments."(P3) None -Participants stated that did not observed any sexual behaviour.

Reactions/Behaviours Due to the Demonstration of Sexual Expression
Findings designated a total of 13 categories for 'reactions/behaviours due to the demonstration of sexual expression': 'using humour', 'denying', 'questioning about care', 'questioning about the intention of sexual expression', 'protection of older adults' privacy', 'talking', 'restricting', 'embarrassment and shame', 'asking for help from colleagues', 'empathizing', 'being permissive', and 'infantilizing'.
Using humour -Participants verbalized that FCs use humour dealing with the sexual expression of older adults and that facilitates their job.
"We play with them a lot on all subjects, but also on sex.It makes our job easier, they get distracted."

(P2)
Denying -Participants stated that they prefer to deny than face sexual expression.FCs verbalized not to talk direct about old people's desires or behaviours.
"I pretend that nothing happened and I'm leaving."(P2) "In the bath, when there is a man who has an erection, I pretend that nothing has happened and I continue giving him a bath."(P4) Questioning about care -Participants considered the limits of giving privacy and at same time providing care and questioned how they should provide an adequate care.
"I wonder: "Should we let them go to the room alone or not?"."(P1) "Sometimes we wonder ... do we leave or not?Are they safe in a room with the door closed?" (P3) Questioning about the intention of sexual expression -Participants demonstrated doubts about the intention of old people's sexual behaviour due to mental impairment.
"I wonder why they do it ... is it because they want to or is it by nerve impulses?"(P4) "They seek to express themselves sexually ... but is it not just because they have some sort of dementia?"(P3) Protection of older adults' privacy -Participants revealed the concern to protect other adult's privacy and reveal behaviours such close doors or not telling others about what they saw or hear in the institution.
"I closed the door and did not let anyone peek."(P6) "There was a man who masturbated in the bathroom and we tried not to let anyone know."(P3) Talking -Participants reported that they talk with old people about sexual behaviours comfortably and with no shame.
"Mrs.X could no longer have an active life, but we talked a lot about sex." (P6) "We talk a lot about sex and we have a lot of talk about the past lives.It helps to create a good relationship with them."(P2) Restricting -Participants stated that they restrict and repressed older adults' sexual behaviours, because considered their behaviour as inappropriate.Empathizing -Participants reported that they empathize with older adults, trying to understand their behaviour and providing advices.
"We always put ourselves in their shoes.We do for them what we would like."(P2) "They are people like us and deserve to be understood, even if it is about sex." (P2) Being permissive -Participants declared that they let older adults express freely but with certain institutional limitations.
"If they wanted to, I told them to go to the bedroom."(P2) "Why limit the behaviour of the elderly?If you want, I'll let you do it.And it does not hurt."(P2) Infantilizing -Participants demonstrated that they perceived sexual expression as an adolescent behaviour.
"They, to me, are like children.They end up being kids."(P6) "They look like teenagers wanting to touch me." (P6)

Discussion
This study aims to explore the experiences of formal caregivers towards sexuality among the older adults, and to obtain descriptions of their experiences.In doing so, our results show the relevance of a variety of categories for each theme studied.
Firstly, for 'beliefs about the interest in sexuality', 'health limitations despite the desire' was the most reported category (83.3%).Previous studies have already shown that physical health, cardiovascular illnesses, diabetes and arthritis may influence the expression of sexuality (Helmes & Chapman, 2012;Lindau et al., 2007).
Moreover, the functional level of residents in a nursing home may predict the attitudes towards sexuality in older adults, as showed by Bouman, Arcelus, and Benbow (2007) in a study using ASKAS (Aging Sexual Knowledge and Attitude Scale).It appears that half of the participants consider older adults to be 'interested in sexuality' (50.0%), to have the 'need of expressing sexually' (33.3%) and believe that 'older adults have more sexual experience' (16.6%), which indicates some positive beliefs regarding sexuality in older people.This may be due to the fact that 66.7% of the participants had geriatric qualifications and worked for more than 5 years in the institution (50.0%).However, 33.3% reported that older adults are 'no interested in sexuality' and that older adults do 'not the same ability of expressing sexually' (33.3%), thus demonstrating some negative beliefs towards older adults' sexuality.Despite the shift in societal attitudes and the distancing from stereotypical perceptions of asexual old age, the social taboo associated with sexuality in older age prevails (Holmes, Reingold, & Teresi, 1997;Roach, 2004), and seems deeply rooted even in health care services.These results could be explained due to FCs likely considering most patients to be too sick to be interested in their sexuality as showed by Saunamäki, Andersson, and Engström (2010) in a study using the Sexual and Beliefs Survey in Sweden.The fact that this study's sample came from a nursing home, in which most residents were bedridden or had a severe cognitive impairment may explain these negative beliefs.
Findings indicate 'gender differences' (50.0%), regarding 'widowers having less interested in sex' (33.3%), and 'older adults reserved about sexuality' (16.6%).Furthermore, FC's demonstrate an understanding of older adults' experience of sexuality, as well as being aware of small subtleties that occur in the nursing home context.For example, Hajjar and Kamel (2004) showed that the lack of sexual partner is a barrier to sexual Beliefs and Attitudes Towards Older Adults' Sexuality

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I asked him not to do that, which is dirty, to choose another time, place and such."(P5) "I jumped in and asked him what the hell he was doing."(P5) Embarrassment and shame -Participants told that they felt embarrassed dealing with sexual behaviours."Those times I feel ashamed."(P2) Beliefs and Attitudes Towards Older Adults' Sexuality Psychology, Community & Health 2017, Vol.6(1), 77-92 doi:10.5964/pch.v6i1.216"I'm not comfortable talking about it...The best thing to do is to change the subject quickly."(P2) Asking for help from colleagues -Participants stated that they ask for help from colleagues when they do not know what to do."Then I seek the help of a colleague, I ask they what I should do."(P6) "It is better to have the opinion of a colleague."(P6)

Table 1
Characterization of Participants According to Socio-Demographic and Occupational Variables Reliability between researchers was measured through the Cohen's Kappa.All categories presented a value between .849 and .934,indicating a high agreement rate.Data were analysed using SPSS for Windows (version 19.0; SPSS Inc., Chicago, IL).The William James Center for Research (WJCR) coordination from ISPA -Instituto Universitário approved this study.

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Maybe in men, it is more difficult...They always have to have sexual activities."(P1) "I think older women are more embarrassed."(P6) Participants verbalized that old adults are no longer interested in sexuality and that there is an age limit to having intercourse.Mainly, participants recognized this due to the fact that the majority of institutionalized old people are widowed, have illness or give the notion that are no longer interested in sexuality.
"Sex at this age is no longer important."(P4)"Wehaveseveraloldpeople who are no longer interested in sex ... some are widowed, others say they are old."(P6)Not the same ability of expressing sexually -Participants reported that old adults no longer have the same ability to express their sexuality.FCs point out that this is due to old people's illness, lack of partner or old people's personality."Thesex of the elderly is not as active, but the affection pays off."(P2)"Theirsexualitystill flows, but they have less desire."(P4)Needforexpressingsexually -Participants declare that expressing sexually is a need, like others they have.FCs mention that it is not a question of age and the human being needs to express sexually."Butclearly…they need, it is a necessity."(P1)"A man and a woman together need to have sex.It is abnormal not to do." (P3) Widowers having less interest in sex -Participants reported that old adults without a partner are less interested in sexual activities, because they do not have anyone with whom to have intimacy."Manyhere are widowers.You get to a point in life that they are no longer interested in sex." (P4) "Several old people tell me that they no longer have a partner for intimacy."(P1)

Table 2
Emergent Categories Resulting From Content Analysis