Submitted by Patricia MacGabbann
This paper examines the issue of sexual health and older people. It identifies sexual health in this population group as a component of health that is often overlooked. As a practitioner of Gerontological Nursing, the author seeks to determine why this is and what can be done about promoting sexual health for this population group. Initially health promotion and sexuality are defined before outlining the rationale for the choice of this topic. Incorporated into the discussion is the acknowledgement that this is an area requiring significant development for all older people, regardless of sexual orientation, that in fact the need for health promotion for older gay and lesbian people may be a more pressing issue overall. Having outlined the need for health promotion, a number of strategies are introduced. Relatively little research into this specific issue has been conducted thus health promotion strategies in more broad terms are discussed.
Health promotion is generally accepted to be a process whereby the healthcare professional shares information in order to empower the person to make informed decisions about their own health and care. Falk-Rafael (2001) suggests that in order to facilitate this empowerment nurses must advocate for those in their care without taking over. In other words, the balance of power must shift away from the paternalistic medical model of care and towards the patient as expert.
Sexuality is defined by Béphage (2008 p448) thus, “sexuality and its expression as an activity of daily living that is significant for many older people”. Other writers concur and note that sexuality is a broad concept that encompasses many facets of daily life such as attitudes, body-image, psychological, emotional and social issues. What becomes evident when looking at this definition is that sexuality is not an issue that can be swept aside when seeking to provide person-centred, holistic care for our older population.
Gott (2001) advises that there is limited knowledge regarding the sexual behaviours of older people because to date there is little research and because older people tend not to be included in sexual health studies. If Robinson and Molzahn’s (2007) contention that sexuality and quality of life are inextricably linked is to be accepted, then why is it that healthcare professionals still do not address the issue? For example, Maes and Louis (2011) note in their study that only 2% of nurses stated that they always took a sexual health history when conducting admission interviews with older adults. A further 23% admitted to either rarely or not at all addressing sexual health with this cohort of patients.
Clearly a huge opportunity for health promotion regarding sexual health for this population continues to be overlooked. Nurses cite many barriers to addressing sexual health in the Maes and Louis (2011) study but they relate primarily to factors such as lack of time and constant interruptions.
However, nurses own attitudes may be a more important contributing factor to consider. Despite the stereotype of the older person as ‘asexual’, Gott (2001) notes that almost 82% of research participants remain sexually active into later life. Assumptions, stereotypes and ageist attitudes are inhibiting nurses from fulfilling their health promotion role in relation to sexual health for older patients. Thus, their opportunity to contribute to the quality of life for these patients is not availed of. Robinson and Molzahn (2007) indicate that almost 70% of men and 57% of women with an average age of 60 years cite sexual relationships as important to contributing to quality of life.
If nurses’ attitudes present barriers in dealing with sexual health matters for older people in general how do they effect addressing the sexual health of older gay men or lesbians? Fenge and Hicks (2011) note, that of this particular group of older people only 14% make their sexuality known to healthcare professionals. This occurs because of a number of factors they contend, factors such as fear of marginalisation and discrimination due to staff assumptions of heterosexuality, reluctance of staff to engage in meaningful discussion, or homophobic attitudes.
By failing to address sexuality and sexual health for gay and lesbian older people, they are placed at further risk of health problems such as low morale, poor psychological health, increased risk of self-harm and suicide. Indeed, Fenge and Hicks (2011 p148) note that “failing to respond to individual need...can have a negative impact on both identity issues and dignity of later life”. Older gay and lesbian recipients of healthcare express their feeling of being invisible to the healthcare system. Thus health promotion for all older people is imperative.
Peate (2007) asserts that in 2005 approximately 7% of global HIV cases were adults aged 50 years and over. This figure translates to a startling 2.8 million worldwide. Maes and Louis (2003) suggest a link between the rise in HIV in older adults to the fact that they do not consider themselves at risk of sexually transmitted diseases and aren’t always aware of how these conditions are transmitted. With an increasingly ageing population it seems logical that the sexual health of older adults if unaddressed presents a huge personal and public health issue.
Sexual health is a basic right, regardless of age, sexual orientation etc. Knowing why it is not being addressed is essential to determining what can be done to redress the balance. Price (2005 p18) suggests that healthcare professionals are simply uncomfortable discussing issues of sexuality but also notes that “this approach risks denying the existence of specific health and social care issues”. So what health promotion activities can be undertaken by healthcare professionals?
HEALTH PROMOTION STRATEGIES
The overall purpose of health promotion with regard to sexual health is to empower people to make changes to their behaviours that will positively impact on their health. Further, the nurses’ role is to assist those in his/her care to become more informed about their sexual health and activity in order to reduce the risk of increased morbidity (Barnes 2009). Unfortunately research into the sexual health of older people is sparse. However, empowerment is a central principle of health promotion. Further, empowerment requires nurses to develop a trusting relationship, advocate and empathise and it is these strategies that will be discussed. The common thread of the importance of communication is evident throughout.
Developing a trusting relationship.
It is generally accepted that nurses are ideally placed to carry out health promotion activities. Fundamental to this role is the ability to establish a warm therapeutic relationship with those being cared for. Effective communication is essential to that relationship and building rapport. Successful health promotion requires the nurse to be aware of his/her own communication style and ways in which it may be improved. One communication strategy that can be utilised is that of Motivational Interviewing. This is a strategy that seeks to contribute to readiness to change and can be used alongside the nursing assessment to empower the person to make changes in their own way and at their own pace.
One of the central tenets of MI is the expression of empathy and the building of rapport. Genuine empathy means the person will feel accepted for who they are and their reluctance to disclose personal information, for example in relation to sexual behaviour diminished. Feeling acceptance and respect allays fears of discrimination, judgement and marginalisation.
Essential to enhancing readiness to change is being able to identify a gap between the goal (i.e. improved sexual health resulting from change in behaviour) and current behaviour. What do they know about their behaviour and the associated risk? Do they see changes as important? Through motivational interviewing the nurse is in a position to help the person to identify these issues and to support the person to make the changes, provide assurance and encouragement thus motivating them.
Falk-Rafael (2001) notes that part of the healthcare professionals’ role in health promotion is to act as an advocate on the behalf of the person in their care. Advocacy is widely considered to be a key component of health promotion and allows healthcare professionals to act on their patient’s behalf to facilitate access to care and support, promote their rights and ensure they have the relevant information and access to support and resources necessary to make informed choices about care. This support and advocacy is also extended to the families of those in our care. For the older people addressed in this paper, that may mean ensuring that they have access to sexual health professionals, can attend clinics without fear of judgement, social prejudice or marginalisation, particularly in the case of our older gay and lesbian patients.
In order to advocate effectively for the people in their care nurses must challenge their own attitudes and behaviour (www.rcn.co.uk). Knowing what this/her attitudes are allows for the development of non-judgemental and open communication, the absence of which will inhibit information sharing by the patient. How often has the section on sexuality on admission forms simply been filled with the words ‘not discussed’?
Fenge and Hicks (2011) note that patients are aware of the reluctance of staff to discuss sexuality and sexual health and consequently they are less likely to disclose important information. Staff reluctance to discuss these issues can be interpreted by patients as indicators of discriminatory attitudes and they fear stigmatisation. What must be borne in mind is that, that fear contributes to wider health problems such as psychological health, increased risk of mental health problems associated with a sense of isolation and fear. So failure to address this aspect of health negatively impacts on other aspects.
Nurses are human and have their own views, attitudes and even prejudices; perhaps they are merely uncomfortable discussing intimate issues. However, as a nurse if these issues are allowed to influence how patients are viewed, assessed or cared for then it indicates a failure to recognise the uniqueness of each individual. It will also inhibit the development of the gold standard of care; person-centred, individualistic, holistic care and will doubtlessly mean that health promotion activity will go unaddressed.
Crucial to the establishment of rapport and empathy is self-awareness on the part of the nurse as already discussed. Empathy allows the nurse to put themselves in the shoes of the person they are caring for. In the instance of our older population, they come from a generation that perhaps did not view discussing sex, sexuality or sexual health as appropriate, they might use different language to describe sexual activity that may require some interpretative skills on the part of the nurse.
An older person may be very socially isolated by virtue of the fact that their partner/spouse may have died and they have no familial support. They may feel that they are being disloyal to their loved one in some way by discussing such personal details. An older gay person , on top of these issues may also have been denied the opportunity to grieve the loss of their partner, due to fear of disclosing the relationship or because they feel that their loss is not attributed the same importance by society as the loss of a spouse (Fenge and Hicks 2011). By empathising with the person, the nurse is allowing themselves to be open to feeling genuine compassion for them. This in turn gives that person permission in a sense to confide in the nurse without fear of ridicule or prejudice and thus facilitates the nurse to instigate health promotion activities.
In researching this paper, it has become evident that health promotion in relation to the sexual health of our older population continues to be overlooked. While there are many reasons why this has occurred, the onus is on healthcare professionals to be aware of their own attitudes and even prejudices. They must also, as advocates for those in their care, challenge policy, procedure and practice not only at a local level but at a national level too. Failure to challenge and address shortcomings in our healthcare provision simply perpetuates the status quo. It keeps our older people isolated and our older gay people fearful and marginalised. Healthcare is not perfect, healthcare professionals are not perfect but in challenging the status quo and seeking to promote health for our entire population the gold standard of individualised, person-centred, holistic care can be within our grasp.
WORD COUNT 2,042
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