The knowledge and attitudes of staff toward the sexuality of older adults in Polish nursing homes

INTRODUCTION

The population of Poland is aging, in large part due to the reduction in mortality and technological advancements in the medical field, the average life expectancy of Polish people has increased due to 90s (despite the COVID pandemic), and in 2021 it was at 71.8 years for men and 79.7 years for women [1].
In the context of increasing numbers of older people, the sexuality of older adults has become an important issue. On one hand, older adults are at risk for multiple, comorbid chronic health conditions because chronic health conditions become more common with age [2]. Often older adults with a chronic health condition are placed in nursing homes and need to rely on assistance provided by its staff. On the other hand, many older adults remain sexually active, even if they are residents of nursing homes. The fact that sexual health is an important moderator of human psychological well-being in late adulthood [3] emphasizes the importance of providing older adults and their caregivers with adequate knowledge as well as medical and psychological assistance to facilitate positive attitudes towards sexuality.
The ability to express one’s sexuality is also a basic human right and need regardless of one’s age, which demands measures to ensure that older adults have proper conditions and assistance to exercise it, including well-educated and professionally trained staff in nursing homes [4].
This study focused on the knowledge and attitudes towards sexuality of older adults in a group of nursing home employees. Studies show [5] that younger adults do not possess reliable and systematized knowledge on late adulthood – usually they base their judgements of this developmental period on numerous stereotypes, which often have pejorative connotations instead of knowledge. The aim of the study was not only to assess the mentioned variables, but also to investigate whether there is a relationship between the attitudes towards older adults’ sexuality among nursing home employees and their knowledge in this matter, gender, and age. Such a research goal seems especially important in light of studies that show that some of the factors that = influence the sexuality of men and women in late adulthood are existing stereotypes related to the sexuality of older adults [6, 7].
The view that sexual activity is neither necessary nor possible in old age is still a widely held view. Stereotypically, older people are broadly described and portrayed as asexual, unattractive, sexually undesirable, incapable of sex, or having no sexual needs, and their sexuality evokes pity, repugnance, laughter, or even contempt [8-11]. What is interesting, the same sexual behaviours undertaken by young people are described as ‘signs of vitality’, whereas in the case of older people they are, according to the study participants, a ‘sign of lust’ [12]. Sexuality is also associated with youth and its attributes such as a slim and well-built body, smooth and healthy skin, or good physical fitness – such associations lead to the unjustified perceptions that older people (who lack these attributes) are asexual [13].
The 4 main stereotypical beliefs about older adults’ sexuality are as follows: 1) older people are asexual; 2) in older age, people do not have sexual needs; 3) sexual activity might have a detrimental effect on health; 4) in older age, people avoid sexual activity because they are ashamed of their naked bodies [7, 14]. The prevalence of the beliefs mentioned above about the sexuality of people older than 60 years might make older people who want to fit into the accepted social role adjust their behaviour according to unfounded and unjustified social expectations regarding their sexuality. For this reason, it is important to monitor the knowledge and attitudes of nursing home staff because they are not only in power to directly limit older adults’ sexual activity, but also can serve as an important source of knowledge on socially acceptable beliefs about sexuality for seniors.
The purpose of the study was to examine the relationship of knowledge and attitudes of nursing home staff and to assess the readiness and resources that characterize nursing homes in Poland in supporting the sexuality of their residents.

MATERIAL AND METHODS

The data were obtained from a sample of 107 employees of nursing homes in urban areas of central and northern Poland. The sample consisted of 89 women and 18 men and was divided into 3 age groups to study cohort differences: early adulthood (aged 20-35 years, n = 19), middle adulthood (aged 36-55 years, n = 58), and late adulthood (aged 55 years and older, n = 30). The study participants filled in the ASKAS scale anonymously. Questionnaires were distributed by researchers in facilities whose administration agreed to take part in the study. Participation in the study was voluntary.
Participants were informed verbally of the purpose of the study and were asked to complete a set of questionnaires. Participants did not receive any compensation for their participation in the study. All participants provided informed consent, and the study was conducted in accordance with the Helsinki Declaration of Human Rights. Prior to data collection, managements of the nursing homes received a letter of intent for the research, while the research itself was conducted after obtaining management approval for it. Participants’ knowledge on older adults’ sexuality and their attitudes towards this topic were measured using a Polish version of the Aging Sexual Knowledge and Attitudes Scale (ASKAS) [15]. ASKAS consists of 2 subscales. The first one measures knowledge on the sexuality of older adults. There are 21 true and false statements. The task was to respond to them by marking one of 3 answers: True, False, or Don’t know. Cronbach’s α for the subscale was 0.78.
The second subscale measures attitudes towards the sexuality of older adults. It consists of 23 statements with a 7-point Likert scale each, where 1 means Strongly disagree and 7 means Strongly agree. The reliability of the subscale was satisfactory – the Cronbach’s α was 0.69.
The sex and age of participants were determined by self-report. The Statistica software platform was used for statistical analyses. Data contained no missing values. Descriptive statistics were used to determine sample characteristics of variables, ASKAS items, the ASKAS domain scores, and the percentage of correct answers.

RESULTS

The first problem under study was the knowledge of the nursing homes’ staff on older adults’ sexuality. Factor analysis led to the division of all items into 3 groups: the first one concerns biological components (Table 1), the second one concerns sexual reactions and behaviour (Table 2), and the third one contains items regarding general beliefs (Table 3).
Analysing the data in Table 1, it is worth noting that 78% of participants had knowledge on the positive impact of sexual activity on older adults’ mood (item 9). A substantial majority of participants (69%; item 5) gave an incorrect answer and indicated that they did not know the correct answer.
The second group of items concerned knowledge on sexual behaviour and reactions of older adults.
Most of the study participants did not recognize the influence of social and psychological factors on the sexual activity of the older adults (e.g. double standard of ageing – item 15), although many of them (79%; item 20) were aware that the fear of an inability to perform sexually may bring about an inability to perform sexually in older males. They were also aware that seniors can be satisfying sexual partners for each other (79%; item 14).
Upon analysing the general beliefs of nursing home staff about older adults’ sexuality, it can be seen that most of the study participants acknowledge older adults’ right to feel sexual needs (72%; item 4). However, even more of them do not know that one of the crucial factors in determining sexual activity in late adulthood is the level of sexual activity in earlier developmental periods (76%; item 7).
While creating research questions, we assumed that the level of knowledge on sexuality in late adulthood would be linked to the age (Fig. 1) and gender (Table 4) of the nursing home staff.
The ANOVA analysis (Fig. 1) shows that the oldest staff possess the least knowledge on sexuality of older adults. Nevertheless, the result can only be interpreted in terms of a statistical tendency because the results of the analysis are not statistically significant. Similarly, we did not find gender differences (Table 4). A major disadvantage of the sample was the unequal number of male and female respondents, which should be considered in future studies. However, it fully resembles the demographics in this work group in Poland.
The ASKAS items measuring attitudes towards the sexuality of older adults were divided into 3 areas. The first one (Table 5) concerns the general sexual activity of older adults; the second one (Table 6) concerns the sexual activity of nursing home residents, and the third focuses on the willingness of the participants to broaden their knowledge (Table 7).
Considering the attitudes toward general sexual activity of older adults in the studied sample (Table 5), it should be noted that the participants expressed moderately positive attitudes towards masturbation in late adulthood. Nevertheless, the participants were more eager to declare positive attitudes towards male rather than female masturbation. Nursing home staff report rather negative attitudes towards older persons engaging in recreational sex as well as sexual activity outside of the context of marriage.
The attitudes declared by the staff of the studied nursing homes towards engaging in sexual activity by the residents of these facilities can be qualified as moderately positive. The staff who participated in the study declared their support of social interactions between women and men in nursing homes. However, the attitudes were less positive when sexual activity was directly indicated in the statement as well as in the case of providing various facilities to aid in engaging in such activity (e.g. arranging beds large enough for couples).
Analysing the declarations regarding participants’ attitudes towards acquiring knowledge on older adults’ sexuality, it is interesting that most of them had a rather positive belief about their knowledge in this area, but at the same time they did not negate the possibility of broadening their knowledge. It is worth noting that the participants preferred to educate the residents rather than themselves.
The last analysis concerns determinants of the attitude towards sexuality of older adults (Table 8). We predicted that participant’s age and gender as well as the level of their knowledge of older adults’ sexuality would correlate with the attitudes score.
The results of the correlation analysis indicate no relationship between participants’ gender, age, and declared attitudes. However, this study revealed a statistically significant relationship between participants’ knowledge on the sexuality of older adults and the overall attitude score.

DISCUSSION

In this study, we focused on the knowledge of older adults’ sexuality and declared attitudes towards it in a Polish sample of nursing home staff. Research on nursing home residents has shown that older interviewees believed that sexual activity was appropriate for other older adults in the homes; they personally were not involved, mainly because they lacked such opportunity. Most of them admitted having sexual thoughts and feelings though [16].
The results of research on nursing home staff are not entirely clear. For instance, Wasow and Loeb [16] showed that medical and behavioural personnel showed great reluctance to discuss the subject. In our study, we found moderately positive attitudes in the sample. Similar findings were reported by Bouman et al. [8], who observed moderately positive and permissive attitudes towards later-life sexuality in their study.
In this study, we demonstrated that the attitudes of the nursing home staff towards the sexuality of older adults are associated with their levels of knowledge regarding the sexuality of older adults. It is worth noting the 5 most prevalent myths regarding sexuality of older adults that were found in the study:
1) In old age, sexual activity is harmful to one’s health (the risk of heart attack)
A somewhat worrying finding is that a substantial majority of participants (69%) believed that sexual behaviour increases the risk of heart attack in older adults. Training for nursing home staff should emphasize that frequent sexual intercourse is unlikely to result in a substantial increase in the risk of stroke [17]. Moreover, it has been found that sexual activity in old age has a health-promoting impact on the individual. For instance, it lowers the risk of heart attack and stroke, increases sensitivity to pain, raises the levels of immunoglobulin and testosterone, and it fosters neurogenesis in olfactory brain areas [18].
2) The decline of sexual activity is usually not a symptom of depression
Based on our findings, it seems to be especially important to promote awareness among nursing home staff of the relationship between sexual activity and depression because it is a well-established finding that sexual dysfunction is a common depression symptom. Although decreased libido is reported most often, difficulties with arousal, resulting in vaginal dryness in women and erectile dysfunction in men, and absent or delayed orgasm are also prevalent. Sexual dysfunction is also a frequent adverse effect of treatment with most antidepressants and is one of the predominant reasons for premature drug discontinuation. Selective serotonin reuptake inhibitors are the most widely prescribed antidepressants and have significant effects on arousal and orgasm compared with antidepressants that target norepinephrine, dopamine, and melatonin systems [19-22].
3) Smoking is not linked to sexual activity
Nursing home staff should also be better educated in the course of training regarding the relationship of sexual dysfunction and smoking. Cigarette smoking is associated with a greater probability of complete impotence in men, especially with heart disease and hypertension [23, 24].
4) Most women are unresponsive to sexual stimulation
Sex differences within human sexuality have long been a subject of research. Most reports state that it is men who declare a higher frequency of sexual intercourse and masturbation [18, 25, 26]. Furthermore, attitudes towards extramarital sex in the group of adult men are more positive [27]. Sex differences can be also identified when it comes to the motivation for sexual activity – women more frequently than men declare engaging in sexual activity because of their love for the partner, whereas men more often indicate hedonistic reasons, but also the necessity to fit into social trends and the need to rise to social pressure [28]. However, these differences may be the result of evolutionary and biological differences; studies confirm the presence of the Coolidge’s effect (this is an increase in libido in males as a result of the appearance of a new sexual partner; the presence of this effect in animals allows us to rule out cultural factors). Research also confirms the specificity of men’s attitudes toward novelty and diversity in their sexuality [29]. Askun and Ataca [30] found that men more often than women watched pornography, presented liberal attitudes towards sexuality, and had their first intercourse earlier in life. Similar findings were reported in another study [31], which showed that men had sexual thoughts more often (once a day or more often), compared to (several times a week) women. They also engaged in oral sex more often, declared a higher number of sexual partners as well as the willingness to have sex with a stranger, and their age of initiation was lower. In another study, it was reported that 50% of men and 10% of women in middle age think about sex every day or several times a day [32]. The above-mentioned results might suggest the existence of gender differences in sexual behaviour, but this might be also interpreted as the double standard for sexual activity that gives men greater freedom to manifest their sexuality [27]. Research also suggests that it is women who declare higher acceptance for such a double standard [27]. The existence of a gender difference should not, however, lead to the false conclusion that women are asexual in late adulthood – they do experience sexual satisfaction, especially through touching and caressing [12, 33]. Physiologically, a healthy woman is fully capable of orgasm at any age; in fact, there are numerous medical case histories not only of women who were orgasmic in their 70s and beyond, but also of women who achieved their first orgasm during those years [34, 35].
5) The lack of a relationship with another person leads to a lack of sexual activity
The fifth myth we identified in the studied sample concerned the causal relationship between relationship status and sexual activity such that the former would lead to the latter. Interesting results in this area were provided by Weizman and Hart [36], who surveyed 81 men aged 60-71 years (34 men aged 60-65 years and 47 men aged 66-71 years) about their sexual behaviour. About half of the sample reported regular masturbatory activity. A decline in frequency of sexual intercourse and an increase in frequency of masturbation in subjects aged 66-71 years as compared to subjects aged 60-65 years indicates that the interest in sexuality continues in older men although the form of sexual expression changes from active sexual intercourse to a self-pleasuring/autoerotic form. It is worth noting that most nursing home residents (73%) consider masturbation in late adulthood a good way to satisfy their sexual needs without partners [37]. Furthermore, some clinicians have successfully “prescribed” masturbation to women in late adulthood, who later reported to be able to experiment with and enjoy self-stimulation for the first time in their lives after receiving approval from their health care provider [38].
This study found that the age and sex of nursing home staff was related neither to the knowledge nor to the attitudes concerning the sexuality of older adults. One needs to be careful though when generalizing the findings of the present study to the general population due to an unequal number of participants in the investigated subgroups (women and men; early, middle, and late adulthood). The same limitation concerns gender differences. It is very difficult, though, to acquire a Polish sample with equal numbers of male and female participants because it is usually women who are employed in such facilities in Poland. On the other hand, women make up the majority of the overall health and social workforce, and the sample represents the demographics in this work group. Nevertheless, we were able to find a significant relationship between knowledge on the sexuality of older adults and the attitudes towards it. The myths and lack of knowledge in this area of human functioning are sources of stereotypical perception of older adults’ sexuality. Stereotypes contribute to the cognitive component of the attitudes that thus might contribute also to a biased treatment of older adults only because they belong to a specific social group.
Adequate sexual expression is an essential part of many human relationships and may enhance quality of life and provide a sense of physical, psychological, and social well-being [21].

CONCLUSIONS

Education is a key factor in helping older adults achieve an informed understanding about their sexuality in later life. To make this possible, nursing home staff should possess adequate knowledge on human sexuality in late adulthood, and more importantly they should present positive attitudes towards it. This would prevent them not only from limiting the sexual activity of older adults in nursing homes, but also could help foster their healthy sexual development through the provision of professional knowledge.

Disclosure

The authors declare no conflict of interest.

References