Creating professional environments to overcome barriers to sexuality expression in older people

Topic Overview

As the average life span increases, older people make up a greater percentage of many populations and a substantial percentage of these older people will need to be cared for within a residential and/or nursing care environment. For residential and nursing homes to provide a nurturing environment that promotes the health and well-being of each resident as a whole, opportunities, practices and attitudes should support and facilitate sexuality and sexual expression.

Aims and objectives

Learning outcomes 

After reading this module you should be able to…

  • Understand the importance of creating an organisational culture in long-term care services that support the sexuality expression of older people in care.
  • Develop policies that uphold the rights of older people, staff, and families regarding sexuality and intimate relationships in long-term care settings.
  • Design and provide environments that facilitate individual rights and choices in sexuality expression and intimate relationships.
  • Implement a person-centred approach to care for older people that respects their individuality, cultural background, and beliefs regarding sexuality.
  • Develop sexual expression policies that clarify acceptable forms of sexual expression, establish ethical response strategies, and consider the facility’s cultural and physical environment.
  • Adapt the physical environment of care homes to support and facilitate the expression of sexuality, intimacy, and relationships among older residents.
  • Employ strategies to facilitate open and sensitive discussions about sexuality, sexual dysfunction, and related issues with older persons, ensuring their comfort, understanding and involvement.

Module 3.1

Professional environments in residential aged care

Research has found that sex in late life is associated with pleasure, tension reduction, communication, mutual tenderness, passion, affirmation of one’s body and its function, a sense of identity, and security when facing hazards and losses (Nay, 1992). However, there are a number of hindrances for older adults in long-term care who wish to express their sexuality. Older people in nursing and residential homes often face challenges such as lack of a partner, health concerns, limited privacy, negative staff and family attitudes, loss of self-esteem, cognitive loss, mental illness, and concerns of potential legal/liability by the long term care facility (Hajjar & Kamel, 2003; Lantz, 2004). This combination of individual and institutional barriers suggests that thoughtful and creative strategies are required to address the sexuality related needs of the older person in residential care (Gilmer et al., 2010). At the same time, studies show that although there is a clear desire among many older adults in care to be able to discuss sexual dysfunction or other issue related to sexuality with care staff, older people rarely have discussions about sex with their health or social care professionals and when they do, only minimal information is usually exchanged (Bauer, 2016). Negative attitudes, shame, embarrassment and a feeling that health and care staff are disinterested or have no treatment options to offer can all inhibit discussion. Strategies that promote a safe environment for sexual discussions and sexuality expression should be implemented by health and care services and staff who should endeavour to promote open sharing of information and ensure older people receive the care, support, information, education, and treatment they require (Bauer et al., 2016).

These strategies should include:

  • Creating an organisational culture in a long term care service that is supportive to sexuality expression of older people in care.
  • Developing policies related to sexuality and intimate relationships of older people in long term care which support the rights of older people, staff, and families.
  • Offering environments that facilitate individual rights and choices in sexuality expression and intimate relationships.
  • Using best practices, such as a person-centered approach to care of older people.
  • Offering support and appropriate education and training for staff to support older people with issues of sexuality, intimate relationships and sex.
  • Offering information on sexuality and sexual health for older people in care and their families.

Organisational culture

Staff cannot be expected to provide care, which is based upon dignity and respect, if it is not part of the overall culture of work life and intrinsic to how care teams work (Hirschhorn, 1990). In an organisational culture that recognises and addresses sexuality as a component of wellbeing of older people in care, sexuality is incorporated into assessment and care planning (Bauer et al., 2014). 

In most countries, by law, nursing or residential home residents are afforded multiple rights, many of which are relevant to sexuality. These rights include, but are not limited to, the right to privacy, confidentiality, dignity and respect, the right to make independent choices, and the right to choose visitors and meet them in a private location. These rights must be preserved by promoting attitudes of awareness, acceptance and respect for sexual diversity. A positive organisational culture focuses on raising awareness of issues that can impact upon the sexuality, intimate relationships and sexual activity of older people living in long term care homes and, which can help health and care staff to work effectively with these issues. It can also facilitate learning, support best practice, help health and care staff address the needs of older service users in a professional, sensitive and practical way, which in turn can foster improved person-centred care and better relationships between staff, residents and relatives.

Positive cultures of care for older people are associated with staff feeling well supported and appreciated, along with effective leadership and strong collegial relationships (Nolan et al., 2002). Having a clear policy on sexuality expression, modifying the physical environment to support expression of sexuality, a person-centred approach to care, and education for staff, older people and their families can help to facilitate and maintain a positive organisational culture, with benefits for all.

Sexual expression policy

Sexual expression policies that clarify acceptable and unacceptable forms of sexual expression and establish ethical response strategies so sexual expression can be facilitated in a safe manner and can be developed by nursing or residential homes are important. In developing such policies understanding the benefits and risks of sexual expression among older adults and the facility’s cultural and physical environment need to be taken into account.

Policies should acknowledge and promote a resident’s right to privacy, confidentiality, consent and support to live their lives as they choose, so long as this does not adversely affect the rights of others. Care homes may also wish to develop policies covering specific aspects of sex or intimacy, such as for example, stating that residents who are married, in a civil partnership or in a long-term relationship should be able to share a room/rooms or have privacy during partner visits.

Policies should also acknowledge and promote the rights of staff to work in ways that are morally acceptable to them. Staff should receive adequate education in all aspects of their work with residents. Policies and local management mechanisms should be effective in identifying sexual abuse, protecting staff from sexual harassment, exempting staff from situations where they might feel morally compromised, and supporting staff to work within their comfort zones.

The following considerations should be included in such policies:

  • Recognition and support of residents’ right to express sexualities (providing it does not impinge upon the rights of others).
  • Recognition of right to privacy.
  • Recognition of a resident’s right to use aids/equipment/visuals in their room.
  • Incorporation of sexuality into assessment and care planning.
  • Residents are given the opportunity to discuss their needs with appropriately trained staff.
  • Confidentiality of information where there is no cognitive impairment.
  • Knock and wait for permission to enter requirements before entering rooms (unless in an emergency).
  • Adherence to ‘Do Not Disturb’ signage (unless in an emergency).
  • Unacceptability of discriminatory/sexist/ageist/homophobic language or behaviour in the facility.
  • Staff offer same level of assistance with personal/intimate hygiene care surrounding sexual activity as is given for other activities of daily living such as toileting.
  • Resident’s right to access the services of a sex worker (where legal).
  • Support and assistance for family to understand residents’ rights where the person has a cognitive impairment and where there is a conflict.
  • Support for staff who feel uncomfortable about a resident’s sexual expression.
  • Support for family members who feel uncomfortable about a resident’s sexual expression.

All policies should be reviewed on a regular basis with input from residents, families and staff. In the case of conflict, legislation will always override local policy statements.

There are multiple facets of the care environment that impact a resident’s ability to express their sexuality (Frankowski & Clark, 2009; Heron & Taylor, 2009; Saunamaki et al., 2010; Shuttleworth et al., 2010). Environments should acknowledge that sexuality and relationships are aspects of the overall care agenda and challenge barriers to the fulfilment of these. Environments should also acknowledge sexuality and relationships as integral to life in the care home through pictures, photographs, posters, newsletters or leaflets and other educational material that may be on display in nursing and residential homes. Images can convey powerful messages about the acceptance of love and intimate relationships among people who are older, who are from diverse cultures, have disabilities or choose a partner of the same gender.

There should ideally be:

  • Private space where care can be delivered and open discussions can take place without risk of being overheard.
  • Space where people can sit together in privacy. 
  • Provision of opportunities to express sexuality in a social setting.
  • Residents should be able to request sexually explicit materials to use in the privacy of their own rooms.
  • Residents who wish to exercise their rights to use sex aids should be supported to do so in the privacy of their own rooms.
  • Availability of double or adjoining rooms for residents who wish to live as a couple, including those of the same gender.
  • Availability of double beds.
  • Availability of privacy measures for individuals who are sharing a room and are not a couple.
  • ‘Do Not Disturb’ signs for doors should be available.

A person-centred approach

Person-centred care respects others as individuals and ensures care is organised around their needs. The concept underpinning person-centred care is that there is a focus on the person’s experiences, relationships and uniqueness as an individual. This approach supports staff in getting to know the residents better as individuals by engaging in learning more about the resident, their life experiences and relationships, and considering how these can be related to the care provided.

All decisions related to sexuality expression should depend on the individuals involved, individual circumstances, and a comprehensive assessment of individuals and individual circumstances, including risk, must be undertaken. The views of all key people should be acknowledged when appropriate, decisions should not be made in isolation but with the support of teams caring for individuals.

Acknowledgement of individual cultural backgrounds and beliefs is essential in care homes as these can fundamentally influence approaches to expressing sexuality, sex and intimate relationships. For example, how different cultures view what is regarded as acceptable or unacceptable in terms of sexuality, relationships, sexual behaviour or intimate care (for instance providing care only by a caregiver of the same gender). Person-centred approaches can help to avoid misunderstanding and conflict, and should help to ensure that all people involved feel that their rights and individuality have, to the fullest extent possible, been recognised and respected. In other words, care approaches should promote and support human rights, dignity, privacy, choice and control, while also promoting clear boundaries that protect and support residents and staff. Staff should strive to achieve a balance between an individual’s right to privacy and control with the need for care and observation, for example, residents remaining in bedrooms undisturbed or with locked doors and staff waiting to be invited before entering (Heath, 2011). This focus on individuality emphasises the importance of promoting the independence and autonomy of older people and their involvement in care.

Person-centred approaches should be based on determining the needs of the older person as follows:

  • Assessing and identifying residents’ needs related to sexual expression.
  • Behaviours that impinge on the rights of others should be documented and investigated.
  • Residents should be given the opportunity to discuss the effects of medications on their sexual health.
  • Residents should be given the opportunity to raise and discuss facility supports for the expression of their sexuality and anything that may be impacting on it with appropriately trained staff.
  • Residents should be asked about and given the opportunity to discuss their personal presentation and styling.
  • Residents should be asked if they are satisfied with their opportunities to socialise.

Documentation is central to facilitating the acknowledgement of lifestyle, sexuality and relationship issues for residents. Biographical details can give clues on whether these are issues for individuals and how best they might be approached in the most sensitive and appropriate manner. Significant relationships can be recorded, along with a resident’s priorities for relationships – for example, a couple may want to spend uninterrupted time together or a resident may not want his/her children to become aware of their desire for an intimate relationship. Well-designed documentation can also assist the preservation of confidentiality, and this is particularly important when working with individuals who have a disability that necessitates assistance with intimate personal activities of daily living.

Staff education

Research recommends that the topics on sexuality and sexual expression of older people should be included in educational and training programmes for care staff in residential and nursing homes, along with the strategies for how care should best be provided (Bauer, 2016; Shuttleworth et al., 2010). Furthermore, there is a need for support for staff members who may be uncomfortable with a resident’s expression of their sexuality. Staff should be able to raise issues relating to their experiences at work. For example, during staff meetings open discussions can be encouraged on issues and challenges staff encountered in their practice related to sexual expression in older residents, and staff should be encouraged to discuss and identify actions that might be help to resolve issues so that action points are agreed and reflected on and staff are invited to report back on developments at the next meeting (Ashburner et al., 2004).

Staff should be provided with education on the following topics:

  1. Sexuality and ageing; personhood; dementia; sexual health; risk management related to sexuality expression; managing conflict (families and residents); sexual discrimination; consent and decision-making; privacy and medications.
  2. Guidelines on what is appropriate or inappropriate sexual expression should be available for all (See Additional materials).
  3. Education to help enhance staff understanding in relation to cultural and religious beliefs, and learning resources and support should be readily available.
  4. Differentiating sexuality and behaviours of other unmet needs. For example, if a resident is removing his clothes this could be seen as a problem for staff or visitors who feel uncomfortable. In fact the problem may be for the resident who wants to go to the toilet but is unable to communicate his needs, recognise where the toilet is, or make the journey independently. Action in this situation should focus on staff recognising the signals the resident is offering, improving the environment in terms of signs clearly indicating the location of toilets, and providing whatever aids or assistance will help the resident make the journey to the toilet safely.
  5. Guidelines about appropriate and inappropriate levels of assistance staff should offer residents (see Additional materials).
  6. Communication skills for staff to assist them to respond to residents and families (See below “Strategies to facilitate discussion of sexuality or sexual dysfunction or other related issues with older persons”).
  7. Record keeping and confidentiality of information.

The following assessments need to be performed to ensure that staff have appropriate knowledge on sexuality and sexual expression in older persons.

  • The availability of written information on sexuality for staff.
  • The provision of summaries of relevant legislation relating to privacy, guardianship and residents’ rights.
  • Appraisal of staff attitudes towards sexuality before and after education.
  • Competencies for staff qualified to have conversations about sexuality and collect information.
  • Competencies to evaluate staff performance in respecting residents’ rights.
  • Competencies with respect to staff knowledge of policies and procedures around sexuality.
  • For senior staff/management – dealing with issues of concern raised by staff.

Strategies to facilitate discussion of sexuality or sexual dysfunction with older persons

Older people often feel uncomfortable and reluctant to raise sexuality and sexual health issues due to perceptions of negative attitudes and lack of interest and understanding from health and care staff, or due to fear of unknown treatments for their sexual dysfunction or concerns around treatment failure (Bauer, 2016; Colton, 2008). 

Discussing personal or intimate topics requires skill and sensitivity. Health and care staff can build on their understanding of what is the most appropriate approach. Staff can help reduce the discomfort felt by older people in discussions about sexual concerns by adopting a professional demeanour, showing comfort with the topic, being kind, understanding and empathic. It is important to try to time sensitive conversations for when the person might be most ready to speak. Staff should also aim to create an atmosphere conducive to uninterrupted discussion, initiating the conversation, using open-ended questions, being non-judgmental, avoiding abbreviations or jargon and being receptive to clues, however subtle, which the person may offer in terms of what is really important to him or her.

Opportunities to discuss sexuality issues can arise during conversations about physical health issues and starting from general topics they can progress to more specific and sensitive topics. Two routes into discussing sexual issues are suggested by White and Heath (2005):

  • The direct impact of illness or its treatment on expression of sexuality or on intimate relationships.
  • The relationship context through such questions as ‘Who is around for you?’, ‘Who are you close to?’ or ‘Who is important in your life?’

It is essential to be respectful of the person’s response. Although an initial reaction could be something like ‘That’s not important’ or ‘What, at my age?’, and further disclosure is unlikely at that time, such responses can indicate a willingness to discuss the subject and further opportunities for discussion should be sought as appropriate.

If individual staff member feels they are unable to support a resident’s right to sexual expression, managerial support and supervision or education can be offered. In the meantime, the resident’s care can be referred to another member of staff who is comfortable dealing with sexuality issues.

Strategies to facilitate discussion of sexuality or sexual dysfunction with older persons

As many older generations did not have access to sex education and sexual health education when they were younger, it is important to provide relevant information on these topics.

  • Availability of information for residents in a format they can understand on: sexual health; consent; assault; sexual orientation/identity and discrimination and rights; sex following illness such as a stroke or a heart attack; and information on sexually transmitted diseases.
  • If requested, information for residents on sexual aids/lubricants/condoms and audio-visual aids or in large print should be available to accommodate the needs of people with sight or hearing impairment.
  • Information materials should be available in language appropriate for residents.
  • Information should be provided to residents that trained staff can discuss sexuality and psychosexual issues and provide support where desired.
  • Information on who to approach if there is perceived abuse and/or discrimination.

Information and support for families

  • Education on older adults’ sexuality and rights.
  • Availability of identified and trained staff to support families.
  • Availability of written information on sexuality (in a format the family can understand).

Safety and risk management related to sexual expression in residential aged care.

A risk assessment should be performed on residents to determine any safety issues connected with expression of sexuality (e.g. a fall from a bed, condom use, etc.).

In addition, the residential and nursing home facility should investigate, act on and prevent behaviours that impinge upon the rights of others or cause others to feel harassed.

  • Chemical or physical restraint should not be used except in a crisis situation where the risk of harm to residents or staff is present.
  • An individualised activity programme that is meaningful for residents with dementia who display behaviours that may impinge upon the rights of others should be available.
  • Staff should be trained to assess the ability of a resident with dementia to consent/assent to intimacy on an episode-by-episode basis.
  • Staff needs to be assessed on their knowledge of current legislation surrounding sexual abuse or reportable assaults.
  • Staff should be trained to recognise signs of unwanted sexual contact.
  • Staff to be trained to recognise signs of sexual assault or abuse (past and present).


As average life span increases and older adults make up a larger percentage of the population, it has becomes crucial to address sexuality and sexual expression of older people in residential and nursing care environments. Research has demonstrated that sexual activity in late life is associated with various benefits, including pleasure, tension reduction, communication, affirmation of one’s body, and a sense of identity and security. However, there are several barriers that hinder the expression of sexuality among older adults in long-term care, such as lack of a partner, health concerns, limited privacy, negative attitudes from staff and families, cognitive decline, and legal concerns. To address these challenges, it is important to implement strategies that promote a safe and supportive environment for sexual discussions and sexuality expression. This includes creating an organisational culture that values and supports the sexual expression of older people in care, developing policies that protect the rights of older people, providing environments that facilitate individual choices in sexuality expression, using person-centred approaches to care, and offering education and training for staff to support older people with issues related to sexuality.

Additionally, the physical environment should be designed to support privacy and intimacy, including private spaces for discussions and socialisation, availability of sexually explicit materials in residents’ rooms, provision of double or adjoining rooms for couples, and respect for residents’ privacy preferences through measures like “Do Not Disturb” signs. A person-centred approach is vital, which involves understanding and respecting each individual’s unique needs, preferences, and cultural background. Documentation should capture biographical details and significant relationships to facilitate appropriate and sensitive care. Staff should receive education on sexuality and ageing, cultural beliefs, communication skills, and the differentiation of sexuality from other unmet needs.

To facilitate discussions about sexuality or sexual dysfunction, health and care staff should adopt a professional and empathic approach, create a comfortable and non-judgmental environment, and provide appropriate information and support. Policies and strategies should be regularly reviewed and revised based on input from residents, families, and staff. Overall, promoting a positive organisational culture, developing comprehensive policies, ensuring a supportive physical environment, and providing education and training for staff are essential steps to address the sexuality-related needs of older people in residential and nursing care settings. By implementing these strategies, we can create a more inclusive and supportive environment that respects the rights and well-being of older adults in their expression of sexuality.

Module 3.2

Overcoming barriers to social connectedness and sexuality expression in older people living in the community

Topic Overview

The interplay of health and contextual factors puts older adults living in their homes at risk of loneliness and/or isolation. Lonely people are at risk of reduced health and well-being, including poor life satisfaction, depression, low self-esteem, reduced hope, negative affect and impaired functioning in activities of daily living (Lee, 2014; Ong & Allaire, 2005; Van Orden et al., 2013). The opposite of loneliness, social connectedness, is a basic human need that can support the health and wellbeing for older adults (Ashida & Heaney, 2008). Social connectedness is a positive subjective evaluation of the extent to which one has meaningful, close, and constructive relationships with other individuals, groups, or society indicated by: (1) feelings of caring about others and feeling cared about by others, such as love, companionship or affection and (2) a feeling of belonging to a group or community (O’Rourke & Sidani, 2017).

Strategies and interventions to promote social connectedness and reduce loneliness and isolation among older adults that can be used by older people or caregivers include engaging in purposeful activity and maintaining contact with one’s social network. Community-based activities in which older people can take part have the potential to bring them into contact with others and promote social participation, social connectedness and support expression of sexuality for older people.

Aims and objectives

After reading this module you should be able to…

  • Understand the importance of creating an organisational culture in health and social care services that supports the sexual expression of older people.
  • Develop policies that uphold the rights of older people, staff, and families regarding sexuality and intimate relationships in the community.
  • Implement a person-centred approach to care for older people that respects their individuality, cultural background, and beliefs regarding sexuality.
  • Develop sexual expression policies that clarify acceptable forms of sexual expression, establish ethical response strategies, and consider the facility’s cultural and physical environment.
  • Employ strategies to facilitate open and sensitive discussions about sexuality, sexual dysfunction, and related issues with older persons, ensuring their comfort, understanding, and involvement.
  • Explore strategies and interventions to promote social connectedness and reduce loneliness and isolation among older adults, including engagement in purposeful activity and maintaining social networks.

Ageing in Place

When faced with the decision of whether to remain living at home or move to an institutional facility, older adults overwhelmingly indicate their preference to stay at home as long as possible (Mann et al., 2002). This trend, referred to as ageing in place, is closely tied to strong societal and personal values of independence and autonomy. In addition, the familiarity of being at home contributes to well-being and successful healthy ageing. In spite of obstacles, many older people report positive aspects of living in their homes, such as continued social participation and the resultant maintenance of social networks within the community, which includes a sense of belonging that, for many, outweighs negatives or challenges (Carver et al., 2018). Moreover, by staying in their  homes, older adults ageing in place within their communities to which they feel an attachment, tend to be able to continue social involvement and maintain existing roles and supports. Ageing in place commonly provides the most desirable options for most older adults, since it maintains an individual’s independence, community, and connections with friends, family and, if applicable, religious/spiritual community.

Ageing in place is promoted by the World Health Organization to avoid the emotional disruption of leaving home and the expense of institutional care (World Health Organization, 2007). Place is not restricted to principal residence, but can also include the community. Ageing in place allows older adults to remain at home if they wish to, in spite of declining resources or functional abilities as a result of illness, injury, loss of loved ones, and/or loss of income. Those ageing in place often have “a strong drive to stay active and to have meaningful social interactions with others, and they also wanted to contribute to the society” (Fänge et al., 2012, p. 1). If the goal of ageing is to do so successfully, three important factors that can predict the degree of success are the ability to age in place, to maintain attachments to social networks and physical environments, and to overcome barriers to being able to do so (Carver et al., 2018). Social interaction and keeping active are thus, important factors to support successful ageing and promote healthy ageing in place (Bacsu et al., 2014).

Lived Experience and Successful Ageing

Lived experience is defined as the way people feel about and understand their choices and actions. Lived experience combines the experience of the physical self along with introspection, interactions with others, recognition of changing abilities, and generally, adaption to them, and for some, ageing brings deeper meaning, increased spiritual engagement, and a feeling of having a better life after many years of hard work (Shin et al., 2003). The term ‘successful ageing’ is an important construct, since it focuses on assets and abilities and encompasses the process of adjusting to change, including changes in sexual expression and sexual activity, which occur over the course of one’s life (Chapman, 2009). Contrary to disengagement theory, which suggests that withdrawal from interaction is the natural culmination of ageing, those who age successfully commonly continue to participate in the community, maintaining social capital through relationships with others, with the community, family, friends, and romantic relationships (Carver et al., 2018). Continued engagement with life, personal growth, generativity, integrity, and reconciliation are all vital to this stage of life. For many older people the goal is to attain wisdom and pursue meaning, and older adults’ lived experience reflects this (Vogelsang, 2016). In terms of sexual activity and expression, older people tend to place more emphasis on the quality of a relationship with a partner and other aspects of sex, such as emotional closeness and intimacy, with less emphasis on physical sensations. These recalibrations surrounding sex allow older people to feel sexually satisfied, which tends to be different from their sex life in earlier years (Erens et al., 2019). Thus, developing a comprehensive view of sexuality is especially important for those for whom sexual intercourse is not desired or is no longer possible because they lack a partner or are in poor health. Comfort (1976) highlighted many years ago that older people benefit from information and acceptance concerning non-genital forms of sensuality and sexuality and that most welcome such information. Moreover, he found that older people who do have romantic partners derive pleasure from a wide range of nonsexual courtship and dating rituals including dressing up for a date and the sensuality of hugging and cuddling.

Promoting companionship in later life

There is a need for sociocultural changes that recognise the value of companionship in later life. Ageism is a particular barrier that prevents changes in attitude toward companionship for older people in their later life (Dhingra et al., 2016). Day care centres for active ageing, assisted living communities for senior citizens, peer support interventions, and psychosocial support through contact with volunteers, either in person or through the telephone, are some of the interventions that have been explored for promoting companionship in later life (Lunt et al., 2018; Rane-Szostak & Herth, 1995). Training of family and professional caregivers has also been explored in relation to the manner in which it can facilitate improvements in the quality of engagement and promote appropriate companionship in addition to a focus on assisting with basic daily activities (Chung et al., 2017). For example, recognition of the importance of such services has encouraged some home care agencies to include this in the range of services offered to older people (Zeltzer & Kohn, 2006). 

In a similar fashion, social participation is enhanced by providing supports for older adults that make it easier for them to get out of the house and become involved (Carver et al., 2018). These supports can be as simple as providing accessible transportation or help with house maintenance or cleaning, which facilitate ageing in place and social participation. Other important supports include ensuring that older adults are not prevented from engaging in volunteer and employment activities. The supports required for ageing in place are not necessarily health care services, they are part of the human infrastructure—people to support older people to keep and care for their homes and pets, to drive them, read to them, and check in on them.

Importance of social interactions for successful ageing

Older adults’ successful ageing is often influenced by the ability to participate in social interactions. Social participation is a form of social interaction that includes family relationships, friendships and romantic relationships. Older adults often express a desire to engage in more high-quality social interactions, which may include helping neighbours, getting involved in informal groups, volunteering, visiting restaurants or bars, talking on the phone, going to church or doing other religious activities, meeting with friends, attending arts or cultural events, and going to exercise groups. Social participation has also been shown to have health-protective effects in later life (Douglas et al., 2016; Vogelsang et al., 2016), and participation in activities at the community level and within family groups with loved ones are linked to a sense of belonging, interpersonal social connection, and may be the key to achieving successful ageing (Douglas et al., 2016). Vogelsang (2016) suggested that social participation might be an element in the creation of meaning and helpful in overcoming grief, an issue that is important to many older adults. The ability to be engaged in social interactions is important to ongoing feelings of well-being, which in turn are linked to perceptions of good health and successful ageing (Taylor, 2001).

Companionship issues and sexuality in older people

Loneliness is an unpleasant and distressing phenomenon resulting from inconsistency between an individual’s desired level of social relations and the real level of connections (Bandari et al., 2019). Social isolation is an objective state of having few social relationships or infrequent social contact with others. Loneliness and social isolation are becoming significant public health issues affecting older adults’ mental health globally.

Companionship is defined as “shared leisure and other activities that are undertaken primarily for the intrinsic goal of enjoyment” (Rook, 1987, p. 1133). Unlike social support, companionship aims not to solve a problem or provide aid, but to experience pleasure and may be most valuable in providing positive input to well-being, such as recreation, humour, and affection. That is, pleasurable social interaction is important not so much for restoring the individual to a prior level of functioning, but for elevating the current level of contentment (Rook, 1987).

Factors Contributing to Isolation

Historically, traditional and mostly rural society had many protective factors such as joint family systems with children staying together with parents and supporting them in their late life, older people thus had better social networks reinforced by rituals and customs that promoted family unions. However, with modernisation, especially post-modernisation in recent decades, there has been a dramatic change in every walk of life. In today’s world, demographic and sociocultural changes such as urbanisation, migration, empty nests, increased life expectancy, increased widowhood status, generation gaps in digital literacy, and increased institutionalisation of older adults can all contribute to social isolation and loneliness in older adults (Ramesh et al., 2021). In addition, the COVID-19 pandemic pushed millions of older adults into conditions of social isolation and loneliness.

Effects of Loneliness and Isolation on Physical and Mental Health

Loneliness and isolation have been linked to poor physical health, increased risk for modifiable diseases such as diabetes mellitus, hypertension, cardiac illnesses, metabolic syndrome, and increased mortality (Henriksen et al., 2019). These may be directly related to loneliness or indirectly associated with it because of various adverse health behaviours such as excessive alcohol intake, smoking, and reduced physical activity, which are more prevalent in a socially isolated older population (Ong et al., 2016). This group is also at risk for depression, anxiety, and cognitive decline. Studies have found that there is a reciprocal relationship between loneliness and depression and older individuals living alone are at an increased risk for faster cognitive decline (Donovan et al., 2017). Companionship and friendship can act as a resource that buffers against the losses associated with older age and helps uplift the person’s self-esteem.

The following interventions at individual, community, and society levels have been found to have a beneficial role in promoting companionship in older adults (Fakoya et al., 2020):

  • Personal contact, befriending and mentoring programmes, gatekeeper programmes that connect socially isolated older adults with support services.
  • Contact with family or friends using a variety of technological approaches.
  • Home visits or telephone contact to provide information, services, or support. 
  • Day-centre services, seniors’ clubs, social groups (bus trips, dancing, recreational activities).
  • Skills training (digital literacy training to increase access to resources or interpersonal contacts, social skills training, psychological skills training, e.g., self-esteem or self-management skills to develop and maintain strong interpersonal relationships, etc.). 
  • Service delivery programmes (e.g. the provision of transportation).
  • Models of care (e.g., the integration of plants and animals into the everyday lives of older people).
  • Reminiscence activities (to prompt participants to reflect on past memories or experiences and share them with others).
  • Support groups (bringing together a group of older people who share some common characteristics or life experiences, and facilitating group members to provide emotional, informational, or appraisal support and personal development through exploration of issues that members experienced).
  • Volunteer schemes.

There is a need to ensure optimal safety precautions to prevent any exploitation or abuse of older people receiving services to promote companionship, as older people can be vulnerable to exploitation.

Companionship, romantic partner, sex life and life satisfaction in older people

There is a strong link between a healthy sex life and a higher quality of life and life satisfaction as individuals age (Laumann et al., 2005; Lindau et al., 2007). For example, among women who were sexually active, psychosocial factors (such as relationship satisfaction, communication with her romantic partner, and the importance of sex) were significantly related to sexual satisfaction, whereas age and menopausal status were not (Thomas et al., 2015). Among women who were romantically partnered, the prevalence of sexual activity was high, even for women in their 70s and 80s. Prior studies have suggested that lack of a romantic partner is one of the most common reasons for sexual inactivity among this population group (Hayes et al., 2005; Mercer et al., 2013). For instance, one large cross-sectional study found that although the proportion of women who were sexually active in the previous 6 months decreased with age, if they were romantically partnered, 61.2% were sexually active, including 59.0% of women aged 60 years and older. Romantic partner status was the factor most strongly related to whether a woman was sexually active or not (Thomas et al., 2015). 

Health and social care professionals’ and caregivers’ role in promoting sexual expression of older people

To facilitate support for older people to express their sexuality both younger people and caregivers, and the older adults must understand that there should be no sexual thoughts or behaviours denied to older people solely for the reason that they are viewed as age inappropriate. To deny an older person their sexual potential is a denial of civil rights.

There are several ways that can be considered by health and social care professionals, caregivers, and family or friends of older people to support them including:

A lack of privacy inhibits sexuality greatly throughout the lifespan. For older people living alone, privacy is usually not a problem. However, those residing with younger relatives or in nursing homes often have no privacy. Sometimes simply educating caregivers to the fact that an older person has sexual needs can result in provision for privacy. Privacy might consist of an hour of undisturbed time for masturbation or an afternoon alone for an older couple at home.

that are conducted in the same frank and open manner with which other topics of interest to older people such as income, nutrition, housing, and transportation are addressed. Through matter-of-fact discussions of sexual matters, older people can feel supported and can appreciate that their caregivers do not think them incapable of sexual thoughts or activities and do not expect them to be asexual.

One way for a younger person to show an older person that their sexuality is respected might be to ask the older person for advice on or an opinion about a sexual matter, assuming both are comfortable enough with each other to do so. The act of giving advice validates an older person’s image of self as a sexual being. Another way is to listen to the sexual concerns of the older person.

in the same way that such seminars are offered to other groups throughout the lifespan. The risks of infection that can be transmitted sexually need to be recognised and minimised. Indeed, sexual transmitted infections are often more common in older groups, in part because of a view of older people as asexual.

such as frequent visits by hairdressers/barbers or clothing consultants.

and other loved ones to give permission to their older family members to enjoy their sexuality.

as older people participating in regular sessions of moderate exercise enjoy enhanced libido in comparison to sedentary people of the same age.

 For example, research has been conducted with the goal of assisting paraplegics to enjoy sexual feelings (Pettigrew et al., 2017).

for example through the media, civic groups, and through educational television networks.

Sexual and gender identity and ageing in place

Ageing in place may be the best way to guarantee autonomy and privacy for both single and coupled members of the LGBTQ+ community and, in turn, reduce barriers to expression of their gender and sexuality. However, LGBTQ+ older people are often a particularly disadvantaged group as they face the double issue of ageism and heterosexism, and thus their experiences are often largely invisible (Chaya and Bernert, 2014). For example, one study found that half of older non-partnered lesbians reported some level of isolation from support networks (Butler, 2018). Older LGBTQ+ people might be concerned about later-life care owing to strained relations with their biological families or lack thereof. For instance, as lesbians age and require assistance due to illness or disability, and since they usually are less likely to have spouses or children than their heterosexual peers, they may be more likely than their heterosexual counterparts to turn to informal support of friends, rather than to formal service networks. However, friend informal caregivers can typically provide less personal care and receive less support than more traditional family caregivers, leaving older lesbians with unmet needs that then must be filled by formal long-term care services and supports (LTSS). Concern how they will be treated in the LTSS network and experiences of discrimination in the health-care system throughout their lives may cause some older lesbians to resist accessing such formal assistance even when their informal supports are inadequate (Butler, 2018).

Ongoing research supports these findings and highlights the need to create support groups and informative programmes about the healthcare rights of older LGBTQ + people and sexual health in later life, as queer adults deserve the same respect and independence from healthcare professionals as everyone else (Ezhova et al., 2020). By designing and implementing specific support groups for older LGBTQ+ people, health and social care providers can facilitate participants to share feelings, discuss potential issues and talk to other older adults who may have the same sexual and/or gender identity as they do. Health and social care professionals can also benefit from these support groups as they can have the opportunity to better identify queer individuals’ specific needs, provide education and resources to maintain a higher and healthier quality of life experiences, and evaluate the success of sexual health programmes. Many healthcare providers are not appropriately trained or culturally sensitive to the needs of older LGBTQ+ people (Simpson et al., 2018). Therefore, training programmes should address misconceptions among staff regarding sexuality and promote the use of non-biased and open language that can help to transition older LGBTQ+ people into more comfortable environments (Ezhova et al., 2020).

Health professionals’ role in supporting sexual health of older people

The notion of sexual health, as with physical health, is not simply the absence of sexual dysfunction or disease, but rather, a state of sexual well-being that includes a positive approach to sexual relationships and anticipation of a pleasurable experience without fear, shame, violence, or coercion. The complexity of stigma and ageism prevalent in many societies often leads to older people’s hesitancy to seek consultation with a professional on sexual health issues. This deepens the reality of the unique biological, psychological, and social challenges faced by older adults seeking advice or treatment around sexual health issues, which require correspondingly unique and appropriate responses from healthcare professionals, including openness, knowledge, and competence to promote an open, accepting environment in which sexual issues can be discussed.

Health care providers can introduce sexual topics by asking whether there are any difficulties with intimacy as part of routine reviews or examinations. In this way, a comfortable environment can be created in which sensitive issues may be discussed. The responsibility does not fall solely on general practitioners. Many different healthcare professionals should be familiar with the differential diagnoses of male and female sexual dysfunction. 

It is important for older men and women who are interested in preserving their sexual capabilities to avoid, as much as possible, allowing chronic illness to interfere with sexual functioning. Carrying on this aspect of an older person’s life improves self-image and, hence, often improves the medical prognosis for a patient. Knowledge about sexuality at older ages among health care professionals should improve patient education and counselling, as well as the ability to clinically identify a highly prevalent spectrum of health-related and potentially treatable sexual problems. 

Moreover, health professionals can dispel some myths about health risks of sexual intercourse. For instance, the oxygen used in intercourse is roughly equal to that used in climbing a couple of flights of stairs (Butler & Lewis, 1988). Except in cases of unusual severity, the danger of a coronary attack during sexual activity is slight and can be minimised by taking nitroglycerin tablets prior to sexual encounters. It is conservatively estimated that less than 1 % of sudden coronary deaths occur during intercourse (Walbroehl, 1988). In fact, anxiety and tension caused by restricting sex are considered to be greater risks than is the physical risk from participating in intercourse (Butler & Lewis, 1988). Health professionals have an integral role in helping older adults to remain sexually healthy and to express their sexuality in whatever manner they choose, regardless of age.

At the same time, it is important to note that there is commonly a misconception that older adults are not at risk of sexually transmitted diseases, and therefore there is no need to ask about sexual history or discuss sexual behaviours. Indeed, the rate of sexually transmitted infections (STIs) among those aged 55 years or older has consistently increased and has more than doubled over the past decade (Steckenrider, 2023). Furthermore, STIs may not be investigated adequately in this population and thus may go untreated for long periods of time or be mistaken for other illnesses that better fit the ‘age’ expectations (Bodley-Tickell et al., 2008). Given the past and current sexual experiences of this generation of older adults, their sexual risks should come as no surprise. Many older people rarely consider using protection because they came of age at a time when sex education in schools did not exist, HIV was virtually unheard of, and their main concern in seeking protection was to avoid pregnancy. Today, older adults are more likely to participate in the hook-up culture of casual encounters and condomless sex, which might be further encouraged by the availability of drugs for sexual dysfunction, and the increased use of dating apps for older people.

Discussing sexual health issues with an older person

Most older patients are willing to talk about their sexual concerns, but are reluctant to start the discussion. They should therefore be invited by the healthcare professional to engage in discussion, and thus the healthcare professional needs to be able to talk about sex openly and in a comforting manner. In spite of a potential feeling of discomfort or even worries of offending or embarrassing an older patients, health professionals need to be proactive in discussing sexual concerns and making sexual health a part of routine health care (Steckenrider, 2023). 

Physicians are perfectly comfortable initiating discussions about bowel movements, an equally private health behaviour, however, sexual health discussions are commonly avoided. A sexual health problem could be a warning sign of an undiagnosed condition, a side-effect of medication, or an indication of a sexually transmitted infection, all of which are potentially treatable and important to include in a physical assessment. Health professionals need to ask their older patients about sexual history and normalise conversations about sexual health. A brief screening tool at check-in could identify sexual concerns. Discussions can then begin with an explanation that such questions are asked of all patients, are important to overall health, and that patient responses are confidential. This type of discussion can create an opportunity for the health professional to provide information about sexual changes that occur with aging and create a comfortable environment for the older person to share sexual concerns (Ramesh et al., 2021).

Taking a sexual history

Most of the curricula focus on pathological aspects of sexual functioning tends to limit aspects such as general sexual wellness, education, and healthy sexual functions. This can be compounded by concern about embarrassment from both professionals and patients and ambivalence while collecting a sexual history. The principles of taking a sexual history include the following aspects (Kingsberg, 2006):

  • Understanding the barriers to taking a history such as lack of knowledge, fear of effects caused, use of vocabulary, role of ageism, etc.
  • Ensuring the patient’s comfort physically and mentally.
  • Assuring total confidentiality.
  • Interviewing couples either individually or together.
  • Taking a sexual history in the initial periods of history taking.
  • Using open-ended and nonthreatening questions.
  • Taking an appropriate psychosocial history.
  • Taking a thorough medical and psychiatric history.
  • Reviewing medications and substance use history.
  • Making a formulation and management plan.

In addition, the PLISSIT model was developed by Annon (1976) to discuss sexual health among all age groups. PLISSIT is the acronym for:

P – Permission: asking permission for history taking, exploring broader aspects of sexual expression.

LI – Limited Information: gather all aspects of history, examinations, lab investigations, review of medications, education, and screening regarding sexually transmitted infections, providing information on normal sexual functioning patterns in ageing.

SS – Specific Suggestions: identify the dysfunctional phase of the sexual response cycle and look for possible medication side effects or effects of general medical conditions.

IT – Intensive Therapy: both pharmacological and psychosocial interventions and refer to a specialist if required.

As sexual activity has extremely important and positive effects on physical and mental health, evaluation of sexuality should be a part of geriatric evaluation and the role of sexuality in successful ageing should not be neglected.


The interplay of health and contextual factors puts older adults at risk of loneliness and isolation. Loneliness and social isolation have adverse effects on physical and mental health, including increased risk for diseases, depression, anxiety, and cognitive decline. Lived experience plays a significant role in successful ageing, as older adults continue to participate in the community, maintain social relationships, and seek meaning and purpose in life. Companionship and social interactions are crucial for successful ageing and can contribute to emotional well-being, including in the realm of sexuality. Older adults tend to place more emphasis on the quality of their relationships and other aspects of sex, such as emotional closeness and intimacy.

Promoting companionship in later life is essential and requires sociocultural changes and various interventions at individual, community, and societal levels. These interventions can include personal contact programmes, technological approaches for maintaining contact, social group activities, skills training, support groups, and volunteer schemes. Health and social care professionals, as well as caregivers, have a role to play in promoting sexual expression and supporting older adults in this area. Providing privacy, access to erotic literature or media, and arranging open discussions about sexuality are some ways to support older adults in their sexual expression.

Overall, recognising the importance of social interactions, companionship, and sexuality in older adults’ lives is crucial for promoting their well-being and successful ageing. Implementing strategies and interventions to reduce loneliness, enhance social connectedness, and support sexual expression can contribute to a higher quality of life for older adults.

Funded by the European Union. Views and opinions expressed are however those of the author(s) only and do not necessarily reflect those of the European Union or the European Education and Culture Executive Agency (EACEA). Neither the European Union nor EACEA can be held responsible for them.Project Number: 2021-1-FR01-KA220-ADU-000026431

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