43RESEARCH
"Love in the Later Years...": Perceptions of Sex and Sexuality in Older Indian Adults — a Qualitative Exploration
«Любовь в позднем возрасте...»: восприятие секса и сексуальности у пожилых людей в Индии (качественный анализ)
doi: 10.17816/CP153
Original Research
BACKGROUND: The world faces global population ageing. With this demographic shift and increased life-expectancy, healthcare services are focused on healthy ageing. Sexual health is a vital yet neglected dimension of general health and wellbeing in older adults. This study aimed to explore sexual experiences and perceptions of sexuality among older people in India.
METHODS: A qualitative approach with social constructivist paradigm was used. 20 participants aged above 60 years were recruited through purposive sampling until thematic saturation was reached. In-person, in-depth interviews were conducted using a semi-structured guide after an initial pilot study. They were audio-recorded, transcribed, and translated verbatim. Thematic analysis was conducted, and rigor ensured through triangulation and respondent validation.
RESULTS: The overarching categories were "sexuality as a mode of resilience", "emotional stability and intimacy as attributes of sexual pleasure", and "lack of sexual rights awareness". The main categories (themes) were sexual experiences (intimate touch, non-penile sex, personal meanings of sexuality), partner expectations (companionship, support, continuity of care, proximity), and barriers against sexual expression (social stereotypes, stigma, lack of audience in healthcare services). The older people were accepting of their sexual difficulties and coped through relationship dynamics. Participant voices are discussed with regard to the socio-cultural context.
CONCLUSION: Sexual wellbeing is connected with "ageing well". Our findings suggest that older people retain sexual desires and fantasies through changed patterns and expectations. Healthcare services, policymakers and academia need to be informed about older people's sexual needs and rights.
ВВЕДЕНИЕ: Население мира стареет, в условиях демографических изменений и увеличения ожидаемой продолжительности жизни ресурсы здравоохранения направлены на поддержание здорового старения. Сексуальное здоровье — важнейший аспект поддержания общего физического и психологического здоровья
Debanjan Banerjee,12 TS Sathyanarayana Rao34
1 Apollo Gleneagles Multispecialty Hospitals, Kolkata, India
2 Advocacy and Public Awareness Committee, International Psychogeriatric Association (IPA)
3 JSS Medical College and Hospital, Mysore, India
4 JSS Academy of Higher Education and Research (JSSAHER), Mysore, India
Дебанджан Банерджи,12 ТС Сатьянараяна Рао34
1 Многопрофильная больница Аполло Глениглс, Калькутта, Индия
2 Комитет по информированию общественности, Международная психогериатрическая ассоциация (IPA)
3 Медицинский колледж и больница, Майсур, Индия
4 Академия высшего образования и исследований (JSSAHER), Майсур, Индия
ABSTRACT
АННОТАЦИЯ
пожилых людей, при этом ему уделяется недостаточно внимания. Цель проведенного исследования — изучение сексуального опыта и восприятия сексуальности у пожилых людей в Индии.
МЕТОДЫ: Проведен качественный анализ с применением парадигмы социального конструктивизма. 20 участников в возрасте старше 60 лет включались в исследование путем целенаправленного отбора до достижения тематического насыщения. Были проведены индивидуальные очные углубленные опросы с использованием полуструктурированного руководства, составленного по результатам предварительного пилотного исследования. Аудиозапись опросов была расшифрована и переведена. Выполнен тематический анализ, точность которого обеспечивалась с помощью перекрестной проверки и проверки респондентами.
РЕЗУЛЬТАТЫ: Были выделены следующие общие категории тем: «сексуальность как проявление психологической устойчивости», «эмоциональная стабильность и близкие отношения как атрибуты сексуального удовольствия» и «недостаточное понимание сексуальных прав». Определены следующие основные темы: сексуальный опыт (интимные прикосновения, секс без проникновения, восприятие своей сексуальности), ожидания от партнера (дружеское общение, поддержка, постоянная забота, психологическая близость) и факторы, препятствующие сексуальным проявлениям (социальные стереотипы, стигматизация, отсутствие поддержки со стороны структур здравоохранения). Пожилые люди признавали наличие трудностей в сексуальной сфере и пытались справиться с ними в процессе построения отношений. Анализ ответов респондентов выполнен с учетом социокультурного контекста.
ВЫВОД: Сексуальное благополучие связано с концепцией здорового старения. Согласно результатам нашего исследования, у пожилых людей сохраняются сексуальные фантазии и сексуальное влечение, но при этом наблюдается изменение моделей сексуального взаимодействия и ожиданий от партнера. Медицинские учреждения, законодатели и научное сообщество должны обратить внимание на сексуальные потребности и права пожилых людей.
Keywords: sex; sexuality; experiences; older people; old age; qualitative
Ключевые слова: секс; сексуальность; опыт; пожилые люди; пожилой возраст; качественный анализ
INTRODUCTION
Sexuality is defined as a "capacity for sexual feelings and includes a person's sexual orientation, gender identity, intimacy, eroticism and social aspects of sex" [1]. Besides the reproductive significance, anthropologists consider sexuality to be a core aspect of socio-cultural organizations that is influenced by lifestyle, religious beliefs, and family structure [1, 2]. Sex and sexuality remain the primitive tenets of living and have been associated with health and wellbeing. Sexual wellbeing among older persons thus assumes importance as the global population above 60 years is projected to reach 2.1 billion by 2050 [3]. Despite the popular myth, older people cannot be considered as asexual [4]. They are known to have sexual desires, fantasies, varying sexual expectations, as well as change in sexual approaches with ageing [4, 5]. However, the majority of evidence to date focuses on the psychobiology of ageing and sexuality, whereas their lived sexual experiences are hidden and laden with taboo.
In "Sexuality, health care and the older person", Bauer et al. [6] stress the importance of sexuality to older
people and underline that it remains a "neglected area necessitating research". In particular, there is a need to explore experiences of sexuality and sexual diversity in later life. A recent systematic review of qualitative research on "sexual aging" revealed that couplehood, socio-cultural aspects of sexuality, and illness impacted sexual behavior among older persons. The authors stressed upon the importance of "personal meanings and relevance" attached to sexuality in later life and the research gap in this particular field [7]. Several longitudinal ageing studies have supported the fact that sexual health forms are an integral component of wellbeing in later life as older people retain their sexual desires in spite of the physiological changes that come with age. These aspects are frequently neglected both in clinical settings and in the literature [8, 9]. With increased life expectancy and myths surrounding sexual life in older age, it is vital to hear their sexual "experiences"and "unmet needs". This may help to break the stigma, promote help-seeking behavior, and incorporate the findings in healthy ageing policy interventions. Furthermore, considering that
healthcare services have undergone a paradigm shift towards rights-based approaches and healthy ageing, the dimension of sexual health in older people needs to be highlighted in research.
In light of this, our study aimed to understand the perceptions of sexuality in older people in India and the barriers they face in expressing them.
METHODOLOGY Approach
The study followed a qualitative approach with a social constructivist paradigm. This paradigm conceptualizes knowledge as socially based and the researcher can seek multiple social truths as opposed to the hypothesis-driven direction of a positivist approach [10]. We were interested in understanding the experiences and perceptions of sexuality in older people. Lived experiences cannot really be rated and are best expressed in rich verbal and written accounts. Hence, we chose the qualitative approach, which enables in-depth gathering and analysis of non-numerical data.
Setting
The study was conducted in the Psychiatry Department, JSS Medical College and Hospital, Mysore. Individuals were interviewed in separate rooms outside out-patient hours based on their convenience and willingness. These interviews took the form of one-to-one meetings between the participant and researcher, which was audio-recorded with consent.
Sampling and recruitment
Men and women above the age of 60 years, irrespective of marital status, living arrangements, and sexual orientations were invited to participate in the study. We tried to ensure maximum socio-demographic diversity in the sample. However, each participant was screened for
mental health conditions using the MINI Neuropsychiatry Interview 7.0.2 [11]. (Institute purchase) and also the Hindi Mental Status Examination (HMSE) [12]. Only cognitively healthy (HMSE >24) individuals without any psychiatric issues were included in the study as experiences of mental illness or neurocognitive disorders can potentially color their perceptions about sexuality. Individuals with severe mobility restrictions and neurological conditions were also excluded.
Overall, 20 older adults were recruited through purposive sampling from senior-care centers, the psychiatry out-patient department, and other old-age support organizations via advertisements. The recruitment notice was also shared via personal networks and social media.
Procedure
The purpose and mode of study was explained to the participants in their own language and written informed consent was obtained. Separate consent was obtained to allow audio-recording of the interviews. In-depth interviews were conducted by the first author using the interview guide. Open-ended questions were supplemented by probes and memo writing to elicit rich responses. The interviews were conducted in the clinic (November 2019 - February 2020) based on mutual convenience of the participant and researcher. The average duration of interview was 98 minutes but could last between 1-3 hours. Sampling was continued until thematic saturation was reached.
Our main research question was, "How do older people view and experience sexuality, what do they expect from their partners, and what role does sexuality play in their lives?". Based on the existing literature and clinical experience of the researchers, a semi-structured interview guide was formed, which was further refined after a pilot interview phase conducted with four participants. The key questions of the final interview guide are reported in Table 1.
Table 1. Semi-structured interview guide used for the study (only key questions)
• What role does sex and sexuality have in your life?
• How do you perceive sexual relationships?
• How do you feel about your sexual fantasies and desires?
• How do you think your age influences your sexual experiences?
• How would you describe your romantic and sexual encounters with your partners?
• How has your sexual life changed?
• How often do you describe your sexual concerns? What are your experiences related to the same?
• What do you think about 'sexuality in later life'?
• Please describe your current sexual life
Transcription and translation
Interviews were conducted in English, Hindi, and Kannada as appropriate. Each interview was transcribed and translated verbatim to English. The translation and transcription were conducted by the second author, who spoke all three languages. To ensure reliability, translations were back-translated to the respective languages (by other members of the team) to retain what the content was supposed to convey. Each participant's data was numbered, and these serial numbers were used for all purposes related to documentation and analysis. With the exception of the researchers, no one else could gain access to this data.
Research governance or ethical approval
The study was approved by the Institutional Ethics Committee, JSS Medical College and Hospital, JSS University, Mysore (Approval Letter No. JSSAHER/BeSc/Psy/281-76B dated 21st September 2019).
Data analysis
Braun and Clarke's thematic analysis was used to analyze the data [13]. The analysis was completed independently by the first and second authors, who were both trained in qualitative research. Initially, line-by-line coding was conducted throughout the transcribed content. Initial coding was followed by a focused coding to group the codes into meaningful categories, themes, and sub-themes. Finally, axial coding was used to help establish an appropriate hierarchy among the generated themes. The theoretical perspective of research question was taken into account along with the interview memos to ensure that the generated themes coherently convey the participants' stories. A constant comparison between the generated themes and the interview content was performed throughout the analysis to ensure that the participants' voices were reflected in the results. After independent analysis, the final results were collated, discussed, and merged.
The trustworthiness and rigor of the study were ensured through methodological triangulation. Methodological triangulation was achieved by independent coding by two reviewers and respondent validation. The preliminary results of the study were presented and discussed with 50% of participants. Following respondent validation, researchers refined the results, ensuring that they accurately reflected the participants' views [14]. We were mindful of the possible psychological reactions among the participants that could be incited while describing their sexual experiences. In such
cases, they were offered professional help by a qualified sexologist who was not otherwise involved in this study.
RESULTS AND DISCUSSION
The results described here reflect participants' perceptions and experiences of sexuality. The relevance of their experiences needs to be understood based on the individual context. Hence, there can be "multiple truths" in their experiences.
Table 2. Socio-demographics of the sample
Characteristic No. (n=20)
1 AGE (years)
60-69 8
70-79 10
>80 2
2. CURRENT PARTNER
Married/cohabiting 11
Single 2
Divorced/separated 2
Widowed 5
3. ORIENTATION
Heterosexual 18
Transgender — male 2
4. RESIDENCE
Urban 12
Semi-urban 5
Rural 3
5. EDUCATION
Never formally educated 3
Up to Class 10 6
Up to Class 12 5
Graduate and above 6
6. LIVING ARRANGEMENT
Alone 3
With partner 12
With family 5
7. WORKING STATUS
Still in employment 5
Pensioner 10
Financially dependent 5
8. SELF-REPORTED HEALTH STATUS
Excellent 5
Good — average 11
Poor 4
9. REPORTED NUMBER OF LIFETIME
SEXUAL PARTNERS
None 1
One 16
More than one 3
10. MEDICAL CONDITIONS (as per reports)
Diabetes mellitus 5
Hypertension 6
Hypothyroidism 5
Osteoarthritis 4
Gout 2
Vision difficulties 8
Hearing impairment 5
Theoretical saturation was achieved after interviewing 17 participants. Three more participants were interviewed in order to add richness to the obtained data. The average age of the participants was 69.2 years. 10 were men, eight women, whilst two identified themselves as transgender. The majority of participants were from urban and semiurban backgrounds, lived with their partners, and were formally educated. Only a few availed themselves of social support services while nearly half received a pension. Medical conditions were documented as per the records available. 15 participants welcomed the research and were keen to discuss their sexual experiences, while the others needed some time to feel comfortable. Eventually, all the participants stated that they were glad they had participated in this study. Socio-demographics of the sample are depicted in Table 2.
In qualitative research, verbatim excerpts of the interviews with the participants form the real data which needs to be understood and interpreted based on their individual social context are used. The discussion here involves contextualizing a particular theme supported by verbal excerpts from participants' interviews. Separating the participant excerpts and discussion thus becomes redundant and the lived experiences (results) lose their relevance. Hence, we choose to present results and discussion together. The categories and themes generated are reported in Table 3. The overarching categories were "sexuality as a mode of resilience", "emotional stability and aging well as attributes of sexual pleasure", and "lack of awareness about sexual rights."
Perceptions related to sexual encounters in later life
This theme was central to our study objectives defining main experiences of our participants related to sexuality. These were "touch as an index of intimacy", "perceived sexual satisfaction beyond physical stimulation/pleasure", and "personal meanings/contexts attached to sex". Here we discuss these themes and the participant excerpts that support them.
Ageing brings about physiological changes which may affect sexual life. 12 participants expressed their interest in non-vaginal sexual practices and considered various forms of 'touch' to constitute measures of erotic pleasure. In fact, in our sample, sensual touch and affectionate touch (stroking, fondling, kissing, holding hands, hugging, etc.) were the most common forms of expressing intimacy.
As Mr. M (67 years) noted:
"Every time she held my hand tightly, I could feel a sensation in my chest. The same feeling as the olden days. I wanted to keep her close to me and convey my love to her."
Mrs. P (76 years) remembered similar forms of intimacy with her late husband:
"The best moments of togetherness that we shared were when we hugged. I wanted him to stroke my hair as always. At this age, this makes me so happy. I cannot recall a better moment of pleasure. It changes so much with age, doesn't it!"
Table 3. Categories and themes generated in the study
Categories Themes
Perceptions related to sexual encounters in later life • Touch as an index of intimacy • Perceived satisfaction beyond physical pleasure • Personal meanings attached to sex
Expectations from partner • Companionship and support • Continuity of care • Physical proximity and intimacy
Barriers in discussing sexual health issues • Stigma • Social stereotypes about sex in later life • Dismissal in healthcare services
Unmet needs related to sexuality • Lack of audience/understanding • Orientation and age-based discrimination
Overarching categories
• Sexuality as a mode of resilience • Emotional stability and aging well as attributes of sexual pleasure • Lack of awareness about sexual rights
Affiliative touch can serve as a reward stimulus that is known for evoking feelings of pleasure and reducing negative mood state [15]. A 1988 study among 80-102 year-old people found caressing to be the most common form of sexual expression [16]. Since the landmark experiment of Harlow, social touch is known for expressing companionship, social cohesion, sexual intimacy, and emotional bonds. Modulation of hedonic touch sensations depends on attention, contexts, mood, and expectations, varying widely based on central sensory processing [17]. Medical comorbidities such as chronic pain can exist in old age, and the motivation-decision model of pain shows how pain modulation can occur by varying motivational state, which is in turn dependent on perceived closeness with one's partner [18]. Research has shown that the experience of sexuality and sensitivity of erogenous zones change with age [4, 5, 8], as older people prefer physical closeness, emotional warmth, and intimacy over sexual intercourse, which was also noticed among our participants.
Mr. S (70 years) added: "We retained our sexual desire just like before. But how we enjoyed it kind of changed. We turned on in the company of another, especially when I could sense her leaning against me. I cannot see well enough, but her closeness was enough to make me feel loved."
Similarly, emotional intimacy was considered to be far more important than physical pleasure while discussing sexuality.
Mr. M (65 years) remarked: "Frankly, my private parts were not enough sensitive like younger ages. But that never prevent me from getting aroused now. It's difficult to explain you know, it's like a sensation, a fulfilment in your mind. Being loved, knowing that you have your partner to love you. That is what makes it so pleasurable (...)"
Mrs. T (68 years) said: "You must be knowing that sexual desire will decrease over time. I am no exception! Still, you know what — age can never really deprive you of sexual pleasure. Just the meaning changes. It is so intense (...) All throughout our 20s-40s, I have thought these are the best moments you can spend with your partner. Now things have slowed down, but even when we are together and when we have better times — this sensation deep inside me keeps my desire alive."
According to traditional Indian practices, old age has been associated with acceptance and renunciation [19]. Sexual changes in normal ageing are wrongly attributed to asexuality and unattractiveness. However, sexuality is not just about sexual intercourse. The emotional component is equally vital to perceived satisfaction. Our participants mentioned that even though there were variations in arousal, erection (in males) and vaginal lubrication (in females), these responses mattered less than the 'emotional satisfaction' that they derived from their partners' company. 15 of them equated a sense of orgasm with the perceived pleasure of being "emotionally secure" with their spouses or partners. Based on the existing literature, existential anxiety and loneliness in later life are often mitigated by strong interpersonal bonds and social cohesion [20, 21]. Sexual intimacy in later life manifests in more abstract ways than measurable genital responses among our participants, indicating that the index of pleasure differs with age. Also, the response and perceptions about sexual cycle in older people is non-linear. A recent qualitative study by Towler et al. [22] explored older adults' experiences of societal stigma towards sexuality in later life. The authors concluded that body-image focus changes from aesthetics to functionality and emotional wellbeing, and this discordance often leads to difficulties among participants. On the other hand, older people in our study were comfortable with this change in "body-image focus" and rather perceived it as a component of healthy ageing. This seems possible, as this sense of 'withdrawal' from the body and focus on the soul and inner attraction of one's soulmate is advocated in the Vedic traditions and in the Indian treatise of sexual literature, the Kama Sutra [23].
This brings us to the next theme within the perceptions, namely the personal contexts to sexuality. Our study responses show that each individual has unique meanings attached to their sexual experiences in later life. The majority had a positive outlook towards sexuality. This also had socio-cultural and religious connotations and varied between men and women.
Mr. T (71 years) noted:
"Every time I had a successful sexual encounter with my wife, I felt that I am still alive and that live is worth living. It made me feel like myself."
While sexuality was associated with vitality and masculinity, sexual vigor was linked to physical health among men and past marital relationships, time lived with husband/partner, loss of spouse, and companionship among women.
Mrs. L (72 years), while discussing her husband's demise, added:
"I miss him very much. He left us two years ago. I remember the times that we shared, our togetherness and how dearly I missed him when he was away. That still arouses me at times, in a better way... you know what I mean. I feel so complete..."
"Oh, it's very difficult for us you know, you cannot even imagine... It is so difficult to find a right partner among us who truly understands you, knows what you desire from them. Once he is gone, you are so, so alone. The world rarely cares for you, it never bothered about our identity, more so now that I am old."
Western literature mentions that change of partners or "second couplehood" due to divorce or widowhood to have a positive effect on sexual encounters in older people [24, 25]. Sense of freedom, sexual experimentation, openness, and attempts to meet unfulfilled desires are increased [26]. However, in our study, the widowed women preferred to remain single, either cherishing the perceived satisfaction and memories of their spouses or wanting to retain their autonomy and the social barriers to finding another suitable partner. They also found self-worth in alternative familial roles.
According to Mrs. D (62 years):
"It has never been difficult for me even though it's been six years that my husband passed away. Financial challenges, yes! But rather than again going through the hassles of finding a suitable partner, I am rather happy enjoying my role as a mother and grandmother."
16 of our participants felt that medical conditions, medications, and physical mobility concerns adversely affected their sexual experiences.
Mrs. S (67 years) added, "I could hardly move. The gout was all over. Movement caused pain. How could I enjoy intimacy even at its best when it was always paining!"
Mr. W (65 years) felt that his medication list was too long, "Firstly there were 15 pills throughout the day, and I
need to remember them. Then, most of the afternoon and evening I am drowsy and feel difficult to focus. Even if I wish to, how do I enjoy sex?"
Expectations from partner
Relationship expectations from partners change with age. The main themes that emerged under this category were 'compassion and emotional support', 'trust in continuity of care', and 'physical closeness/intimacy1.
Existing qualitative literature has shown that the perception of sexual pleasure changes with age [5, 22, 27]. Our study further adds that our participants felt trust, compassion, closeness and emotional support to be associated with sensuality, even when actual sexual intimacy was challenging for the couple. Intimacy was more associated with safety rather than sexual pleasure through physical stimulation.
Mr. M (78 years) told: 'Things were changing. Now I am barely able to walk. She has been there beside me my whole life. We have had our own ups and downs. When you ask what sensuality means to me now, I can say 'her company'. The times when she is with me, even in silence, I feel that there is someone to take good care of me till I die. That is an immense amount of pleasure, whichever way you put it..."
According to Mrs. S (67 years): "Our marital life hasn't been very smooth. But now after 35 years, I expect I can trust him for the rest of my life. Sex is not the same as it was years back, now it is more of closeness. in body and mind!"
Even though the search for new relationships has been mentioned in the literature [28, 29], in our study such a theme was absent. This could be due to the social norms associated with age that expects one to mourn the loss of and remain loyal to one's spouse. Also, sexuality was limited to fantasies, visual and print media, in contrast to online dating. Digital literacy among older people is minimal in India which, together with generation stereotypes, could have contributed to this [30].
There are a number of gender differences that are worth mentioning. For men, ability to maintain an erection and ability to ejaculate was a central point of concern. However, a few also mentioned difficulties with sexual fantasies and arousal. As mentioned previously, sexual vigor was correlated with masculinity.
Mr. W (65 years) was worried, "Sex was there. Sexual interest was there. But due to joint pains and weakness, I was too slow. It didn't feel like a 'man'. I was afraid what my wife will think about me. We have had so many good moments..."
Mr. P (69 years) expressed shame, "I could not even face myself. Did the decline of hormones rob me of my manhood? I even avoided speaking to her. It was shameful!"
Although previous studies have shown that sexual dysfunction with ageing is associated with low self-esteem, negative affect, and marital discord [31, 32], our study showed that despite issues with arousal and erection, men coped with acceptance and practiced alternate forms of intimacy (foreplay: cuddling, caressing, stroking, etc.) and quality couple time. The supportive nature of relationships often compensated for such sexual difficulties. This 'buffering' effect of couples' relationships in old age has been also seen in the findings of the English Longitudinal Study on Ageing (ELSA) [33]. For five of our participants, who had pre-existing marital issues, sexual satisfaction was reduced irrespective of sexual performance.
As Mr. F (70 years) mentioned: "I knew that I am not the same as before. I had even problems in turning in bed. It took me quite some time to come to terms with it. But I could — sexuality for me was different. It was no longer aggressive and hours of passion. It was much more peaceful. Hours spent together in the presence of my wife, made me happy and loved for..."
Mrs. P (69 years) added: "Yes we still have sex. Quite often even. Do we enjoy it? Maybe yes. But you know, the age-old scars that you have developed in marital life — it cannot really make you satisfied or provide you with pleasure no matter how intimate you are. You need that inner connection in this age, that's what matters!"
This is in line with a British study by Hinchliff and Gott showing that sexual problems amongst older people have a negative impact on their long-standing relationships with their partners/spouses [34]. However, the transgender men in our study expressed negative attitudes towards sex, reduced expectations from partners, reluctance in search of new relationships, and acceptance of their gender identity. This was also influenced by social stigma and ageism.
Mr. N (61 years) replied, "I won't say I have lost interest in sex. It's more like I have been oblivious to it now. Years of difficulties, abuse, and challenges in survival — I have now come to terms with what I am, my sexuality, much more than before. Just that, I miss my partner and really do not want to engage in a relationship again at this age."
In general, our female participants were more descriptive in their responses about sexuality. All of them concluded that although the frequency of sexual activity and sexual expectations of their partners changed with age, the desire for intimacy did not. Common challenges were partner's medical issues, caregiving, lack of partner (widowhood), and social expectations.
Mrs. S (68 years) mentioned: "It is wrong to say that I do not want to get aroused any further. However, his osteoarthritis causes a lot of pain... you know... making things difficult."
90% of our female participants felt that they were relieved to discuss their sexual experiences, yet this was a rare opportunity.
Mrs. L (72 years) noted: "You really expect us to talk about sex! An old woman talks about sexuality instead of spirituality and prayers — how will people around me take it?"
In traditional societies such as India, gender roles are quite fixed and there are sexual inhibitions especially among older women [35, 36]. They are usually expected to be "passive and subordinate" towards their male partners. The choice of initiation is left to their spouses and fulfilling their desires is considered to be their "obligation". With age, the associated expectations change, but the connotations continue to be the same. Women are expected to be supportive of, and act as caregivers to their husbands, which effectively makes their voices invisible. In an action research carried out in another developing nation, Brazil, the sexual experiences of six older women from rural settings were analyzed [37]. Obligatory sexual participation based on partner's wishes, sexual control by society, and over-importance of family expectations were predominant themes. Older women in our study expressed reduced sexual freedom as well. All our female participants agreed that this study
provided them with some form of catharsis with respect to sexual experiences. They welcomed sexual fantasies and desires, unlike an earlier qualitative study from Poland where the themes among women were "I am glad that sex does not concern me anymore" and "I am just happy with my memories" [38].
Mrs. M (64 years) complained: "We are expected to always remain supportive and good. Why is that? Because society expects us. What are our sexual needs? Nobody has asked. I am glad that this age finally someone wanted to know about my experiences!"
The older women in our study emphasized the importance of emotional bonding in comparison with intimacy. They were accepting of the sexual challenges associated with ageing but considered intimacy important to their wellbeing. However, sexual freedom outside relationships was discouraged. The majority did not approve of the usage of aphrodisiac medication in their partners and were afraid of "sexually unrestrained men". They feared that this will take off the "feel good inner experience" that they would rather enjoy at this age. These findings differ from a systematic review on sexuality and sexual health in older adults, suggesting that more sexual freedom and experimentation in older women is what? Common? [7]. However, disapproval of medication and considering "aggressive sex" to be a "risky business" were themes that were similar to those in our study. The body-image narrative in our participants changed from aesthetic-focused to inner peace and "beautification of soul", as they felt that their partners now know them "close enough to just stay attracted physically".
Mrs. F (75 years) concluded: "Times change, we change. It mattered less to me how much physically handsome my husband was anymore. It was about closeness — how much of him do I get for myself? Do I perceive that as enough? That was what I really wanted."
Mrs. T (65 years) mentioned, "I do not want sexuality to be masked by medicines. Every age has its own beauty. Let us accept each other as we are and find new ways of being closed rather than depend on a pill for momentary pleasure..."
Social norms, religion, education, financial independence and general health were other factors that influenced
their sexual desires. These factors have also been found in earlier studies [9, 25, 28].
Mr. P (70 years) spoke about his beliefs, "I have always seen my parents and grandparents move away from worldly pleasures when they aged. I considered that possibly thinking about sex at this age is bad. Somehow, even though I enjoyed sex, in some corner of my mind it did not feel right."
Mrs. T (61 years) was worried about privacy, "My pension was stuck, and my husband never got one. We had to depend on our children and whatever space we got in the house. Intimacy cannot occur without a relaxed space."
The other interesting theme was caregiving and sexuality. Most women were caregivers for their male partners which led to the role transition and, hence, impaired sexual experiences. The caregiver often perceived childlike feelings for the person they cared for, the intensity of which was related to the degree of caregiving. Earlier studies have both reported sexual challenges and improved intimacy associated with caregiving [39, 40]. In our sample, most of these couples stayed alone and, due to the lack of social support, the burden associated with caregiving must have been significant.
Mrs. P (68 years) told: "Most of my time was spent in looking after him, just like a baby. I even had to lull him to sleep and keep him calm. He would not listen to the paid caregiver. Now you tell me — how do I have sexual excitement in these circumstances! I even felt guilty!"
Barriers and unmet needs
Sexuality is widely considered as a tabooed topic in India especially in old age [41]. Social stigma, myths related to sexuality in late life and stereotyped thoughts (both in general public and healthcare providers) formed the main barriers in our participants while discussing sexual issues. Such beliefs are internalized and perpetuated by media discourse leading to the consideration that active sexual life and ageing are mutually exclusive. The common myths included the following statements:
• Older people are asexual
• People should not discuss or talk about sex in later life
• Spirituality and sexuality are antagonistic in older people
• Sexual discussions are akin to sin which deserve shame and punishment
• Body gets unhealthy and weak with age, thus incapable of sex
• One needs to be ashamed and guilty if sexual thoughts occur in old age
• Masturbatory practices are absent in older people
• Older people from the LGBTQIA+ population rarely exist
Few participants mentioned that these myths are still present.
Mrs. S (76 years) mentioned: "Why do you even ask? Who expects us to talk about sex in this age! Isn't it a heinous crime — I cannot even desire to be with my husband in private"?
Mr. M (67 years) commented: "Age is a crime, you know. Suddenly everything is expected to change. As if the person inside me has died! I have even heard words like degenerate and pervert if heard speaking sexual terms. Why — have I lost the right?"
These quotes also demonstrate ageism. The recently released GLOBAL REPORT ON AGEISM by the WHO highlights that one in three adults worldwide share ageist attitudes [42]; indeed, overlap with other forms of discrimination is common. According to the Report, "Ageism often intersects and interacts with other forms of stereotypes, prejudice and discrimination, including ableism, sexism and racism. Multiple intersecting forms of bias compound disadvantage and make the effects of ageism on individuals' health and wellbeing even worse" [42]. Evidently, our participants shared that ageist-discriminatory attitudes as discussing sexual experiences with family and healthcare providers was challenging for them. An Indian epidemiological study in 2015 showed a concerning myth that sexuality is only for reproductive purposes and sexuality is "wrong in the old". Negative reactions related to sexuality in old age were also noted by the family members in this study [43].
In light if this, participants expressed that there is a lack of understanding, audience, and sensitivity to their sexual issues among healthcare providers. It was also associated with self-stigma as many considered sexuality no longer
relevant to their lives and not an integral component of health. Hence, these issues were not discussed during physician consultations. Such beliefs have been discussed in earlier studies [39, 44, 45]. The common reasons for visiting doctors were sexual dysfunction, marital discord, and lack of perceived satisfaction, but these rarely formed the primary reason and were less frequently expressed in reality. 50% of the sample also mentioned lack of guidance if they wanted to know how to improve their sexual health.
Mr. T (72 years) replied: "I don't even understand how to discuss sex with my doctors at this age! Every time I plan to ask him about certain related issues, I feel so deeply ashamed. I somehow divert the topic. Till date I am waiting (...)."
Mrs. P (65 years) added: "My doctor was just dismissive. She said that this age I should go for pilgrimage and read scriptures. Sexuality should be the last thing on my list. I felt offended but you know that's what specially a woman in our society is expected to..."
Mrs. S (63 years) noted: "You do not say, and they never ask. My diabetes and gout were greater problems, and so I did not have a right to discuss sex at this age!"
Feelings of shame and embarrassment were common, as it is expected that one should not discuss sexuality and erotic content at this age [46, 47]. As mentioned previously, this resulted in greater stigmatization amongst women and the LGBTQIA+ community. The latter is nearly invisible in the popular media and health discourse in India [41]. They share the dual brunt of ageism and gender-based discrimination. This can be addressed by putting together sexual health and general issues related to wellbeing, training in sexual health among physicians, and continuous and holistic care. Schaller et al. [48] performed a qualitative study on "how older adults experience talking about sexual issues with healthcare personnel" and defined that Communication dynamics, physician attitudes, knowledge and competence, understanding of sexuality and finally structural conditions influenced help-seeking patterns related to sexual problems among the participants. The authors recommended culture-sensitive attitudes and further research into late-life sexuality, which it was felt could sensitize healthcare providers at all levels [48].
Transgender individuals faced particular difficulties with help-seeking and the literature is nearly absent of any discussion in relation to their sexuality in India. A recent qualitative study during COVID-19 showed impaired psychosexual health, increased othering and multifaceted survival threats in the older LGBTQIA+ community [49]. Their sexual rights are also neglected. Due to other healthcare and social priorities, sexual needs are often neglected in this community.
According to Mr. F (68 years), a transgender male, "People do not even ask us about how we are living — sex is the least that we expect! Even if we are able to make it to the doctor's chamber someday, there are so many other pressing challenges to talk about..."
Overarching themes
Certain themes emerged throughout the analysis and were considered to represent overarching categories.
These were central to the sexual experiences and expectations of the older persons in our study. These categories are "sexuality as a mode of resilience", "emotional stability and 'aging well' as attributes of sexual pleasure", and "lack of awareness about sexual rights." Positive sexual perceptions were associated with better coping in adverse life situations while emotional bonding, better communication, and healthy ageing (with lesser focus on age-related bodily changes) influenced sexual pleasure. Also, the participants largely lacked awareness about sexual and reproductive rights. "Emotional stability as an attribute of sexual pleasure" has already been discussed, so here we will discuss the other two categories.
Awareness about sexual rights was largely absent in our sample.
Mr. N (61 years) was ignorant of such terms, "Are you sure such rights exist... they sound funny. At this age, do I really deserve them?"
Mrs. F (60 years) was surprised as well, 'You mean to say that I can approach the court if such rights are not granted. It sounds so surreal that too being a senior citizen. Please tell me more about it."
Sexual rights not only encompass prevention and treatment of sexual disorders or dysfunctions but also autonomy, dignity, respect and pleasure related
to sexuality and sexual relationships [50]. Various international organizations consider them as fundamental human rights which are necessary for overall wellbeing. Human rights of older people are threatened globally leading to marginalization, sidelining from health services and elder abuse. It is thus important that based on the World Association for Sexual Health (WAS), irrespective of age, individuals stay free from sexual coercion and sexual violence, enjoy freedom of sexual expressions and privacy, sexual justice (legal protection in case of any sexual right deprivation or dispute) and have safe sexual experiences [51]. Hopefully, an international UN Convention for the Rights of Older People, that many organizations are globally in support of, may serve as a tool to protect the sexual and reproductive rights of older people [52].
Finally, sexuality was considered to be resilience-promoting factor among the participants. It helped them in overcoming negative mood states and interpersonal discords. Nearly all the participants mentioned that although sore sexual act was important, "emotional connection"and "intimacy" played a crucial role in building resilience.
Mr. S (69 years) said: "It's not really about your penis or orgasm you know.it's different. The closeness matters. The arousal, feeling good, time spent with my wife makes it so easier even when I am under a lot of stress."
Mrs. T (71 years) added: "Sex is just one way of describing it. We were no longer having intercourse. But his presence mattered. This is a way of sexuality, at least for me. This is my best stress-buster at this age."
There are few Indian studies in this regard. Most research on positivism and resilience in older adults have not factored in sexual health. Popular recommendations suggest seclusion and alternate leisure activities for self-esteem in old age [53]. Alternatively, in the Western literature healthy ageing is associated with better sex life and self-growth. This is further correlated with better self-confidence and freedom from other [46, 54]. Positive sexual expression and better sexual agency have been linked with positive emotions in the Australian "baby boomer generation" study [25, 55]. Psychosocial resilience helps one navigate through stress and is vital for healthy ageing [56]. Since this is a qualitative study, we cannot
form any definitive link between sexual health and resilience but our participant experiences offer insights for exploring the link. Though this link has been studied in sexual minorities and individuals living with HIV, this warrants further research in older people, especially during the present times of COVID crisis.
Strengths and Limitations
To the best of our knowledge, this is the first study to explore experiences of sex and sexuality in older people of India. In spite of the challenges related to social stigma and taboo about the topic, we managed to get a decent sample and all participants provided rich detail of their perceptions. The semi-structured interview guide was framed after a successful pilot which helped elaborate the participant experiences. Another strength of this study is related to its rigorous methodology and measures taken to ensure trustworthiness.
On the other hand, our study has several limitations. Firstly, similar to any other qualitative study, generalized conclusions are rather impossible. However, generalization was not the aim and our findings themselves suggest that sexuality can have unique "personal relevance" to each participant. Secondly, even though we tried to secure a heterogenous sample, most participants were educated, married and from urban/semi-urban areas. Also, representation from the LGBTQIA+ community was limited. Thirdly, adopting a purposive sampling comes with a risk of subjective bias, which we tried to address through bracketing and triangulation. Further, our participants had lesser medical burden which is often exception rather than usual in old age. None of our participants resided in nursing homes or senior care facilities, which form a large proportion of old age population. Sexuality dynamics can be very different in these places due to a number of factors including lack of partners, reduced privacy, overcrowding, personal comfort, etc. Due to inclusive nature of the society in India and stigma related to the subject of our study, we could not get participants from senior living facilities. Lastly, some linguistic nuances may have been missed in the translation-back translation used in our study.
CONCLUSION
To our knowledge, this is the first study from India, exploring sexual experiences in older people. Sexual and reproductive health rights are an integral part of human
rights, and older adults cannot be an exception. Our findings show that older people do enjoy sexuality, retain their sexual desire and interest, even though the forms and intricacies of expression vary. Emotional closeness and companionship were the central core of intimacy, whereas there were several gender differences. Societal myths related to late-life sexuality, misinformation, media portrayals, ageism and inadequate audience in the health sector serve as barriers for them to voice out challenges in this area. According to the UN Decade of Healthy Ageing (2021-2030) [57], physicians and policy makers need to be sensitive towards this neglected dimension of sexual health because it is intricately linked to successful ageing. Sexual minorities suffer from additional stigma which needs to be addressed. Elucidation and education in the healthcare professionals and media are warranted to elicit a general better understanding of sexual desires and their diversity in later life. Older adult's sexual needs should be recognized, respected and implemented in healthcare training, services, research and policy interventions. Physicians irrespective of their specialty need to be trained in protecting sexual rights among older people free of discrimination. Such training needs to be implemented from early days of medical curriculum. Our participants also linked sexuality with resilience and positivity, and it was considered to be a "powerful tool to better couple relationships." This remains a subject for further research, especially if sexuality can mitigate loneliness, the socio-cultural influences and differences in sexual experiences in older people across gender and orientations. Considering sexual wellbeing as a natural part of health, our research provides a preliminary yet firm background to initiate academic and clinical discourse on sexual needs, challenges and experiences of older people.
Article history:
Submitted: 10.02.2022 Accepted: 28.02.2022 Published: 31.03.2022
Funding: The article was written without external funding.
Conflict of interests: None.
Authors' contributions: Both the authors conceptualized and designed the study. DB was responsible for data
collection, curation whereas both DB and TSSR performed the data analysis. DB prepared the first draft of the paper while both the authors edited it. The final version has been read and approved by both the authors.
For citation:
Banerjee D, Rao S. "Love in the later years.": perceptions of sex and sexuality in older indian adults — a qualitative exploration. Consortium Psychiatricum 2022;3(1):62-75. doi: 10.17816/CP153
Information about the authors:
*Debanjan Banerjee, Consultant Geriatric Psychiatrist, Apollo Gleneagles Multispecialty Hospitals, Kolkata, India; Vice-chair, Advocacy and Public Awareness Committee, International Psychogeriatric Association (IPA), ORCID: https://orcid.org/0000-0001-8152-9798, SCOPUS: 57191832268 E-mail: [email protected]
TS Sathyanarayana Rao, M.D. Psychiatry, Professor of Psychiatry, Department of Psychiatry, JSS Medical College and Hospital, Mysore, India; JSS Academy of Higher Education and Research (JSSAHER), Mysore, India, ORCID: https://orcid.org/0000-0002-5727-944X
♦corresponding author
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