The Elephant in the Room – A Critical Interpretive Synthesis of Older Adults’ Sexuality

Abstract

Objectives

This study aimed to explore past studies that have focused exclusively on the sexuality of adults older than 65 from a positive public health approach.

Methods

We performed a critical interpretive synthesis, starting with the literature review on sexual behaviors in later life, adding policy documents on aging sexuality, and bringing new perspectives.

Results

Older adults continue to be sexually active. Healthcare professionals lack knowledge and communication skills surrounding aging sexuality and no policies before 2013 mention aging sexuality.

Conclusions

We posit that society’s view of later life sexuality reflects on practice, policies, and research on this topic, which influence back society’s view.

Introduction

In 2019, there were reportedly more than 700 million people over the age of 65 worldwide, and in the next 30 years, the number of adults aged 65 and older is estimated to reach over 1.5 billion people (United Nations, 2019). In Belgium, the population over 65 years old raised from 1,474,059 in 1990 to 2,204,478 in 2020 (Belgian Federal Government, 2020).

In 2018, the life expectancy at birth of Europeans was estimated to be 81 years (Eurostat, 2019), and their health expectancy at age 65 was estimated to be 9.4 years (Eurostat, 2017). Given this high life expectancy, more attention should be paid to different aspects of older adults’ lives that have not been addressed—such as sexuality.

Sexuality is part of sexual health, which is a fundamental component of public health (World Health Organization [WHO], 2002). Furthermore, sexual health is not only a public health matter but also a human rights matter, as under the umbrella of human rights, sexual health finds an effective way of being promoted (WHO, 2010). The position public health takes on sexuality and sexual health influences society’s view on this matter. Sexual rights are part of a broader context related to human dignity and worth (Parker, 2007). In the past 30 years, there has been a spate of public health research on sexuality. The incentive for sexuality and sexual health research has come from genitourinary medicine and reproductive health, along with activism for safe sex practices. The WHO (2002) states that sexual health requires a positive approach to human sexuality, whether in good health or in the context of disease, dysfunction, or infirmity. However, research on sexuality, and sexual behavior of older adults, in particular, have tended to focus on dysfunctions, being studied in a medical context. We will address sexuality based on this positive approach, stated by WHO. In this paper, the terms “sexual activity,” “sexual behaviors” are used to refer specifically to sexual acts, as opposite of sexual thoughts or sexual desires. We use the term “sexuality” based on the WHO working definition, stating that sexuality is “…a central aspect of being human throughout life that encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.” (WHO, 2006). Therefore, when we refer to the concept beyond sexual activity, including thoughts, desires, beliefs, attitudes, we use the term “sexuality.” According to Papaharitou et al. (2008) , “sexual expression should be a well-informed individual’s choice and not the result of societal myths or health professionals’ misconceptions.” Nonetheless, according to some authors, it seems that the view regarding older adults’ sexuality is the object of misguided representations. Several studies show that older adults are perceived as asexual (Gewirtz-Meydan et al., 2018; Kenny, 2013; Lai & Hynie, 2011). Moreover, healthcare professionals also generally find sexual health as not relevant for older adults, therefore they do not discuss it with them and admit to having inadequate knowledge on sexuality in old age (Gewirtz-Meydan et al., 2020; Gewirtz-Meydan & Ayalon, 2017; Haesler et al., 2016; Soares & Nazareth Meneghel, 2021). The contemporary society idealizes the young body, perpetuating the idea that sexuality is linked to youth and beauty (Goldenberg, 2012). However, studies show that older adults continue to engage in sexual activity (Fileborn et al., 2015; von Humboldt et al., 2021). Several authors have reported strong associations between health and sexual activity in middle-aged populations, such as increased pain threshold, decreased muscular tension, postponement of the natural menopause, decreased risk in prostate cancer and increased longevity (Gianotten, 2021). Lee et al. (2016) reported a link between sexual activity and psychological well-being. Causalities are generally regarded as multidirectional, such as if health plays a role in sexual expression, sexual activity also comes with its benefits and contributes to one’s well-being. Sexual, physical, and mental health and overall well-being seem to be positively associated with sexual satisfaction, sexual self-esteem, and sexual pleasure (Anderson, 2013), and sexual activity, including other forms of affection than sex, seems to be associated with lower levels of depression among older adults (Ganong & Larson, 2011).

Sexual activity can be divided into genital, such as sexual intercourse and masturbation, and non-genital, such as kissing and cuddling. Research shows that affection plays an important role in the association between sexual behavior and well-being (Debrot et al., 2017). Furthermore, it has been suggested that sexuality has a deeper meaning in one’s later life compared to one’s younger years. Non-penetrative sex and aspects related to the importance and quality of the relationship, such as tenderness and care, altruism and gratitude, attractiveness and positive communication seem to be the most important for older adult sexual expression (von Humboldt et al., 2021).

The body of literature on older adults and their sexuality continues to expand; nonetheless, most existing studies had been conducted with younger people, with a cutoff age of 60 or even 55. Moreover, sexuality has been generally discussed negatively, mainly in the context of dysfunctions. Therefore, we aimed to explore the sexual behaviors of adults older than 65 through studies that have focused exclusively on sexuality in a positive way. Although existing systematic and narrative literature reviews on this topic have covered quantitative and qualitative studies (DeLamater, 2012; Sinković & Towler, 2019; Træen, Hald, et al., 2017; Træen, Carvalheira, et al., 2017), none have combined both qualitative and quantitative studies, peer-reviewed articles, and gray literature. This review aimed to better understand sexual behaviors of community-dwelling adults older than 65. None of the previous reviews have examined sexuality in later life from a positive public health perspective, as stated by WHO (2002). To our best knowledge, an interpretive approach has not yet been applied in investigating sexuality in later life. This would bring new insights into the impact of society on sexuality in an aging society.

Materials and methods

This literature review applied the use of a critical interpretive synthesis (CIS), which offers a way of synthesizing diverse forms of empirical and clinical evidence. CIS is a recently devised method of reviewing (Dixon-Woods, Bonas, et al., 2006), which evolved from meta-ethnography, and involves the inclusion and assembling of findings from different types of studies and disciplines. It integrates quantitative and qualitative research, allowing on top of that, the use of gray literature. Gray literature, such as reports, dissertations, and documents from organizations in the fields of aging and sexual health, might shed light on different aspects important for the topic and context being studied. CIS can be an important complement to conventional forms of systematic reviews. Through an inductive approach, CIS leads to a deeper understanding of the topic being studied (Dixon-Woods, Cavers, et al., 2006; Schick-Makaroff et al., 2016). CIS brings “insightful and illuminating ways of understanding the phenomena” (Tricco et al., 2016), particularly useful for policymakers, clinicians, and researchers (Dixon-Woods, Cavers, et al., 2006). The dynamic and iterative process of CIS requires flexibility in the selection criteria, thus making it hardly reproducible. To overcome this difficulty in reproducibility, we applied the key features described by Depraetere et al. (2020).

While conducting this CIS, we critically evaluated the number of studies done in the entire world, that explored the sexual behaviors of older adults. Furthermore, we associated the results of the literature review with the healthcare practitioners’ communication skills regarding sexuality in later life and with existent policies on sexual health in later life. We then reflected on the interaction between what happens in practice, research, and policies regarding the sexuality of older adults.

Conducting this CIS involved several steps: establishing the research question, searching the literature, reviewing identified papers, selecting papers for inclusion, and initiating and reporting the synthesis of data. The reflexive approach before initiating the literature search consisted of formulating the research questions: “Are adults older than 65 sexually active?” and if so, “What are the ways they express sexuality?” The literature research consisted of searches in different academic databases. Based on an analysis of our included studies from the literature, we noted the scarcity of research on sexuality in later life. This led us to question the existing policies on the sexual health of older adults aged 65 and older. After exploring online sources of organizations specialized in sexual health and aging, we included three policy documents from the WHO (WHO, 2016, 2017; WHO, “Entre Nous.” 2013), and one from the World Association for Sexual Health (WAS, 2008).

Records connected with our target population were identified through searching three academic electronic databases—Google Scholar, Ovid PsycINFO, and PubMed—between March and April 2020. The following search terms were used for each database: ‘elderly’ AND sexuality’, ‘older adults’ AND ‘sexuality’, ‘later life’ AND ‘sexuality’, and ‘older adults’ AND ‘sexual activity’. Article titles and abstracts were screened by the first author based on our inclusion and exclusion criteria.

The inclusion criteria for the literature search were quantitative and qualitative research published in English or French (based on the author’s language proficiency) between January 2000 and March 2020; research that included both men and women in their sample, to provide comparisons; and studies with older adults as the only participant population, with the cut off age of 65 for older adults (as per the reference regarding the beginning of old age by the UN). The exclusion criteria were studies with participants younger than 65 years old, studies with participants living in assisted living facilities or nursing homes, because sexuality in institutions is a separate matter to discuss regarding older adults, studies in other languages than English and French, studies with a focus different from the sexuality of older people, studies that included different age groups, as well as studies that focused on health problems or sexual violence. This literature review focused exclusively on the sexuality of adults older than 65 years.

A flow diagram was used to aid in the reporting of our included literature (as per (Mohler et al., 2009)). We initially identified 918 records through an academic database search. After having applied the selection criteria, 12 studies were retained, together with four additional policy documents (“WHO, Entre Nous” 2013; WAS, 2008; WHO, 2016, 2017). The following section presents the results of these 12 studies and the policy documents (Figure 1) .

Figure 1.

PRISMA 2009 flow diagram. Source: (Mohler et al., 2009).

Results of the literature review of sexual behaviors of older adults

Description of included studies

The 12 studies included were from 12 countries: one study was from Australia (Minichiello et al., 2004), one from Italy (Umidi et al., 2007), one from Taiwan (Wang et al., 2008), one from Korea (Choi et al., 2011), one from Spain (Palacios-Ceña et al., 2012), one from the United Kingdom (Flynn & Gow, 2015), one from the United States (Mader, 2014), one from both the United States and Canada (Santos-Iglesias et al., 2016), one from Brazil (Queiroz et al., 2015), one from the Netherlands (Freak-Poli et al., 2017), one from France (Meyrignac et al., 2017), and one from Israel (Even-Zohar & Werner, 2019). Three studies have been realized between 2000 (Minichiello et al., 2004; Umidi et al., 2007; Wang et al., 2008) and 2010 and nine of them between 2011 and 2020 (Choi et al., 2011; Even-Zohar & Werner, 2019; Flynn & Gow, 2015; Freak-Poli et al., 2017; Mader, 2014; Meyrignac et al., 2017; Palacios-Ceña et al., 2012; Queiroz et al., 2015; Santos-Iglesias et al., 2016). Four studies used interviews (Choi et al., 2011; Even-Zohar & Werner, 2019; Minichiello et al., 2004; Santos-Iglesias et al., 2016), six used self-completed questionnaires (Flynn & Gow, 2015; Freak-Poli et al., 2017; Mader, 2014; Meyrignac et al., 2017; Queiroz et al., 2015; Wang et al., 2008) and two combined interviews with self-completed questionnaires (Palacios-Ceña et al., 2012; Umidi et al., 2007). Among the topics studied, eight studies investigated sexual activity (Choi et al., 2011; Even-Zohar & Werner, 2019; Flynn & Gow, 2015; Freak-Poli et al., 2017; Minichiello et al., 2004; Palacios-Ceña et al., 2012; Santos-Iglesias et al., 2016; Wang et al., 2008), five investigated the importance of sexual life and the levels of sexual desire (Choi et al., 2011; Flynn & Gow, 2015; Minichiello et al., 2004; Santos-Iglesias et al., 2016; Umidi et al., 2007), and four investigated communication with healthcare professionals about sexuality (Even-Zohar & Werner, 2019; Mader, 2014; Meyrignac et al., 2017; Umidi et al., 2007). Only three studies explored changes in sexual activity and interest (Mader, 2014; Minichiello et al., 2004; Umidi et al., 2007), two questioned attitudes and knowledge toward sexuality (Even-Zohar & Werner, 2019; Wang et al., 2008), and two explored representations of sexuality among older adults (Meyrignac et al., 2017; Queiroz et al., 2015). A single study explored stereotypes regarding sexuality in later life (Mader, 2014).

The mean age of the participants of the reviewed studies was 72.27 years (Choi et al., 2011; Flynn & Gow, 2015; Meyrignac et al., 2017; Palacios-Ceña et al., 2012; Wang et al., 2008), with an age range between 65 and 90 years old (Even-Zohar & Werner, 2019; Freak-Poli et al., 2017; Mader, 2014; Meyrignac et al., 2017; Umidi et al., 2007). Two of the studies solely included participants aged between 65 and 75 (Choi et al., 2011; Santos-Iglesias et al., 2016). Among the analyzed studies, most of them focused on older adults as one age category, including participants over the age of 65 years old, without comparing the results per age group, such as ‘young old’, aged 65–74 years old, ‘old’, aged 75–84 years old and ‘old old’ aged 85 years old and older. Two studies (Palacios-Ceña et al., 2012), (Freak-Poli et al., 2017) analyzed the results per age group, 65–74 years old, respectively 75 years old and older. The older participants group, compared to the younger participants one, had an increased risk of not being sexually active with age (Palacios-Ceña et al., 2012), as well as engaging less in physical tenderness (Freak-Poli et al., 2017). Although the sex frequency was lower for the oldest participants compared to the younger ones, 55% of men and 33% women reported having sex twice per month (Palacios-Ceña et al., 2012). Two out of three studies that mentioned participants’ sexual orientation included LGBT older adults (Mader, 2014; Santos-Iglesias et al., 2016). Among the three studies that mentioned the participants’ level of education, two solely included participants who had completed high school and had university degrees (Mader, 2014; Santos-Iglesias et al., 2016), and one had a majority of participants with elementary school education (Choi et al., 2011).

Definitions of sexuality used in these studies ranged from broad to narrow. There were three studies with no given definitions (Mader, 2014; Meyrignac et al., 2017; Queiroz et al., 2015). One study investigated the sexual relationship status (Minichiello et al., 2004), one investigated the current sexual life (Choi et al., 2011), one investigated the desire for physical contact (Umidi et al., 2007), and one investigated the number of instances of sexual activity in the past year (Wang et al., 2008). Five studies used the terms “sexual activity,” “sexual behavior,” and “sexual practice,” which included kissing, hugging, or holding hands within their definitions (Even-Zohar & Werner, 2019; Flynn & Gow, 2015; Freak-Poli et al., 2017; Palacios-Ceña et al., 2012; Santos-Iglesias et al., 2016). Table 1 offers an overview of the included studies.

Table 1.

Characteristics of the included studies.

Authors, Date, Country	Sample size	Age	Publication type	Method	Concepts analyzed	Definitions of sexuality
(Minichiello et al., 2004) Australia	844	65+	Research article	Self-completed questionnaire	health; sexual relationship status; changes in sexual activity & sexual interest; sexual health knowledge and beliefs index; the importance of sex for well-being	Actual sexual relationship status
(Umidi et al., 2007) Italy	230	65+	Research article	Questionnaire + interview	marital status; desire; affective and sexual satisfaction; the importance of physical contact in the past; communication with healthcare professionals about sexuality	The desire for physical contact (sexual activity or other types of contact, such as touching or embracing)
(Wang et al., 2008) Taiwan	616	65+	Research article	Interview	sexual activity; sexual knowledge and attitudes;	Number of instances of sexual activity in the past year
(Choi et al., 2011) Korea	156	65+	Research article;	Self-completed questionnaire	importance of sexual life; current sexual life; frequency of sexual relations; desire; satisfaction with sexual life; self-esteem	Currently maintaining a sexual life
(Palacios-Ceña et al., 2012) Spain	1939	65+	Research article	Interview + self-completed questionnaire	sexual activity; frequency; sexual behavior; sexual practices; sexual health	Any sexual practice (kissing, hugging, vaginal intercourse, oral sex, masturbation) with at least one partner in the past 12 months
(Flynn & Gow, 2015) United Kingdom	133	65+	Research article	Interview	sexual behaviors; the importance of sexual behaviors; frequency; quality of life; health	Sexual behaviors: touching/holding hands, embracing/hugging, kissing, mutual stroking, masturbating, intercourse
(Mader, 2014) United States	18	65–85	Doctoral thesis	Interview	experiences of sexuality while aging; context and situations that influence sexuality while aging; talking about sexuality with professionals	Participants talked freely about sexuality, without any definition from the researchers
(Queiroz et al., 2015) Brazil	30	/	Research article	Interview (free word evocation technique)	Social representations of sexuality for older adults	Participants talked freely about sexuality, without any definition from the researchers
(Santos-Iglesias et al., 2016) United States and Canada	297	65–75	Research article	Self-completed questionnaire	frequency of sexual activity; attitudes toward sexuality and aging; sexual satisfaction, sexual motivation, sexual functioning; health	(a) non-genital sexual activities: kissing; hugging & cuddling; whole-body contact or rubbing; (b) genital sexual activities: touching breasts/genitals; oral sex; vaginal penetration or intercourse; stimulation or penetration in the past 3 months
(Freak-Poli et al., 2017) The Netherlands	2374	65+	Research article	Interview	sexual activity; physical tenderness; health	Sexual activity or other forms of physical tenderness (fondling or kissing) in the past 6 months
(Meyrignac et al., 2017) France	15	65+	Research article	Interview	representations of sexuality and their aging bodies; communication about sexuality with healthcare professionals	Participants talked freely about sexuality, without any definition from the researchers
(Even-Zohar & Werner, 2019) Israel	203	65–87	Research article	Self-completed questionnaire	Knowledge and attitudes toward sexuality; frequency of sexual activity; satisfaction with sexual activity; quality of life; communication about sexuality and sexual difficulties with healthcare professionals	Sexual activity was defined by three categories: hugging and kissing; partial sexual activity and full sexual activity

Sexual behaviors of older adults

The percentage of participants who reported being sexually active varied from 36% to 78% (Choi et al., 2011; Even-Zohar & Werner, 2019; Minichiello et al., 2004; Wang et al., 2008). Non-genital sexual activity or physical tenderness showed slightly higher numbers, compared with genital sexual activity: 78% of participants aged 65–74 and 67% of participants aged 75 and older reported having other types of contact than intercourse (Palacios-Ceña et al., 2012). Up to 89% of the participants engaged in touching, hugging, or kissing (Flynn & Gow, 2015). Genital sexual activity was reported with a prevalence between 21% and 71% (Flynn & Gow, 2015; Freak-Poli et al., 2017; Palacios-Ceña et al., 2012; Umidi et al., 2007), although participants from one study reported that 78% engaged in masturbation and partnered sexual activity (Mader, 2014).

One study contrastingly showed that 71% of older adults were involved in fully sexual activity, and only 5% engaged in hugging and kissing (Even-Zohar & Werner, 2019). One study, in particular, reported a very low prevalence of sexual activity among married older adults, with 58% of the subjects having not been sexually active for more than five years (Wang et al., 2008).

Factors associated with sexual activity: health, quality of life, the importance of sex, sexual satisfaction

Most studies measured health either by asking questions related to perceptions of one’s health (Choi et al., 2011; Even-Zohar & Werner, 2019; Flynn & Gow, 2015; Minichiello et al., 2004; Santos-Iglesias et al., 2016; Umidi et al., 2007) or by asking questions related to diseases or illnesses (Mader, 2014; Santos-Iglesias et al., 2016; Wang et al., 2008).

The percentage of older adults who reported excellent, very good, and good health was between 51% (Minichiello et al., 2004) and 79% (Even-Zohar & Werner, 2019). Regarding illness prevalence, ratios also varied: Wang et al. (2008) reported 81% of interviewed older adults as having one chronic disease and 20% having three or more chronic diseases, whereas just 61% of the participants of Mader’s study (2014) reported having illnesses. Regarding sexual functioning, in particular, Santos-Iglesias et al. (2016) reported that 71% of participants admitted having sexual difficulties. As for sexual desire, it seemed negatively impacted by depression, benign prostatic hypertrophy, and hypertension (Umidi et al., 2007), as well as by incontinence (Minichiello et al., 2004).

Furthermore, links between perceptions of one’s health and actual desire were noted (Umidi et al., 2007). Older adults that reported better physical health also reported better sexual well-being and more frequent sexual activity (Even-Zohar & Werner, 2019; Freak-Poli et al., 2017; Santos-Iglesias et al., 2016). Minichiello et al. (2004) suggested that being satisfied with one’s health and physical condition increased nearly five times the chances of being in a sexual relationship. One study found that 17% of older adults dissatisfied with their health and physical condition were in sexual relationships, compared with 42% of those who were satisfied with their health and physical condition (Minichiello et al., 2004). Worse self-related sexual health, having a chronic condition, and medication seemed to be linked to a lack of sexual activity (Palacios-Ceña et al., 2012). A higher quality of life was declared by married older adults and those living with someone (Flynn & Gow, 2015) and by those being in better health and reporting greater frequency of sexual activity (Even-Zohar & Werner, 2019).

Older adults that had a spouse, those who were in a relationship, and those who lived with someone were more likely to be sexually active, compared with those who were not married or not in a relationship (Choi et al., 2011; Even-Zohar & Werner, 2019; Flynn & Gow, 2015; Freak-Poli et al., 2017; Minichiello et al., 2004; Palacios-Ceña et al., 2012; Wang et al., 2008), although unmarried older adults and those who lived alone or were single reported sexual activity as well (Flynn & Gow, 2015; Minichiello et al., 2004). The opposite was also observed, one study reported that 37% of married people were not sexually active or in a sexual relationship (Minichiello et al., 2004).

Sexual life was important and very important for 63% of the participants (Choi et al., 2011). Older adults mentioned the desire to “maintain emotional-affective and physical relations,” the most desired being complete sexual intercourse, and they “were not content with other forms of physical contact.” The same study noted the association between the importance of affectivity and sexuality in one’s past and persistent actual desire (Umidi et al., 2007). Older people who rated sexual expression as important for their well-being were three times more likely to be in a sexual relationship (Minichiello et al., 2004). The ratio of participants who declared themselves to be satisfied with their sexual life varied between 33% and 93% (Choi et al., 2011; Even-Zohar & Werner, 2019). Those that maintained a sexual life, as well as those who were very satisfied with their current sex life, showed higher self-esteem compared with those who were not satisfied with their sexual life (Choi et al., 2011). Contrary to some older adults who no longer saw the sense of sexual activity in their lives, others talked about the notion of pleasure, the desire that was still present, and a continuum with sexual life from before (Meyrignac et al., 2017).

By the age of 80, 92% of women and 71% of men were reportedly less likely to be in a sexual relationship (Minichiello et al., 2004). The most common reasons for sexual inactivity were being a widow/widower, the illness of the partner, and a lack of interest (Palacios-Ceña et al., 2012); Wang et al. (2008) noted the same reasons but in an inversed order.

Communication with healthcare professionals

Older adults expressed the desire for more attention from healthcare providers—including from doctors—regarding the topic of sexual activity and affectivity (Umidi et al., 2007). Even if the general practitioner was widely designated as being the one they would discuss sexual activity with, older adult participants perceived a lack of training in medical studies, especially in terms of the psychological approach of the older adult. Moreover, they thought the doctor would be uncomfortable talking about sex. To ease discussions about sexual activity, doctors should educate themselves about aging sexuality and be more direct in communications, as per participants’ recommendations (Mader, 2014; Meyrignac et al., 2017).

Stereotypes

One study investigated stereotypes regarding sexuality in later life, such as the perception of older adults being asexual. Some male participants in the study mentioned the belief that after a certain age, men would not be able to perform sexually, while other participants feared being seen as “dirty old man” or a “cougar.” In addition, while some of the participants also expressed anger or dislike of these stereotypes, others admitted they had begun internalizing some of these stereotypes (Mader, 2014).

Policies on the sexual health of older adults

The policy documents included in this review discussed the focus of research mainly on sexual vulnerabilities and dysfunctions, to the detriment of the positive aspects of sexuality, and mention the existence of ageism in health care delivery. Also, they admit the lack of guidance or training of healthcare professionals in recognizing and managing problems that matter for older adults and those that are not diseases and raise the question of denial of sexual interest by not giving people the appropriate “privacy and respect required to engage in safe, pleasurable and satisfying sexual lives” (WAS, 2008) (Figures 2 and 3).

Figure 2.

The influence of society’s view of aging sexuality on policies, research and practice.

Figure 3.

Factors associated with sexual behaviors and the percentage of older adults that reported being sexually active.

Legend

Study 1 (Minichiello et al., 2004) Australia.

Study 2 (Umidi et al., 2007) Italy.

Study 3 (Wang et al., 2008) Taiwan.

Study 4 (Choi et al., 2011) Korea.

Study 5 (Palacios-Ceña et al., 2012) Spain.

Study 6 (Flynn & Gow, 2015) United Kingdom.

Study 7 (Mader, 2014) United States.

Study 8 (Queiroz et al., 2015) Brazil.

Study 9 (Santos-Iglesias et al., 2016) United States and Canada.

Study 10 (Freak-Poli et al., 2017) The Netherlands.

Study 11 (Meyrignac et al., 2017) France.

Study 12 (Even-Zohar & Werner, 2019) Israel.

Discussion

This study contributes to the body of literature by focusing on sexual behaviors of community-dwelling adults older than 65. The added value of this work comes from its approach used, i.e., the critical interpretive synthesis, by providing a new perspective, rather than summarizing study results. We started with a literature review on sexual behaviors of community-dwelling adults older than 65. We then subsequently searched for policy documents that would explain the scarcity of research on adults older than 65. Also, we illustrated the importance given by older adults to the communication with healthcare professionals regarding sexual activity in later life and the mentioned impact of the asexual stereotypes on older adults. Conducting a critical interpretive synthesis, we could notice the lack of research on community-dwelling adults older than 65, from a positive public health perspective, as stated by WHO (2002). We are therefore claiming that this topic is under-researched. Eventually, this approach enabled us to bring a new perspective showing how the position of public health reflects society’s attitudes toward older adults’ sexuality. We posit that the society’s view of later life sexuality, such as ageist stereotypes regarding older adults’ sexual behavior, reflects on practice, policies and research on this topic, which influence back society’s view. This perspective is explained below and further research is needed to confirm it. The results of our literature review show that regardless of the variations of sexual behaviors, and based on the importance placed by each individual on sexuality in later life and expressed through sexual intercourse, affectivity, or intimacy, older adults continue to be sexually active.

Nevertheless, we believe that the difference in the percentages of sexually active older adults from these studies might be the result of several methodological shortcomings in the literature. First, although all the reviewed studies considered the concept of sexuality, few explored angles beyond sexual activity, such as affectivity and intimacy. Including affectivity in these studies could shed more light on the importance of sexuality in later life. Different ways on expressing sexuality in old age have been shown in research, with the accent on the importance of tenderness and care and eroticism for older adults who are sexually active (von Humboldt et al., 2021).

Second, the age of the participants in this CIS varied from 65 to 90 years old, although studies concentrated on the age range 65–75. Previous research showed low representativeness of people older than 75 in clinical studies (Murthy et al., 2004). Is this the case here? Is this because it is easier to question young older adults (65–75 years old) compared with the “old-old” (85 years old and more)? Or does this show a lack of interest among the older age group and their sexuality? Talking about sexuality in later life when life expectancy has increased requires including participants over the age of 75 as well. Third, only three studies (Minichiello et al., 2004; Palacios-Ceña et al., 2012; Umidi et al., 2007) in this review considered sexual interest. To enjoy sexual activity, one has to feel sexual desire (DeLamater & Sill, 2005), which has been defined as a motivational state or interest in sexual activity. A study realized in four European countries (Belgium, Denmark, Norway, and Portugal) explored the associations between successful aging, sexual satisfaction, and changes in sexual interest, and most participants reported lower sexual interest in the present compared to ten years ago, a finding that was more prominent in women compared to men (Štulhofer et al., 2019).

Comparing two time frames (2000–2010 and 2011–2020), the only difference noticed was that in the 2004 study, by age 80, older adults “were less likely to be in a sexual relationship.” This could be the consequence of a lower life expectancy, with older adults losing their spouses or partners by age 80. However, similarities between these decades were found, such as the odds of being in a sexual relationship, reasons for not being sexually active, and men being more likely to report being sexually active compared to women (Freak-Poli et al., 2017; Minichiello et al., 2004).

We hypothesize that the dearth of research on sexual behavior in later life may be the result of ageist stereotypes. Policies, research, and practice in this area typically reflect the misguided perception that older adults are asexual. An analysis of five movies that depict sexuality and intimacy in long-term relationships showed that some movies would exhibit scenes of tenderness rather than sex and that two out of five movies had scenes portraying older men not able to complete the sexual act (Doll, 2017).

Yet, a Canadian study that explored the sexuality construct of older adults in newspapers and magazines challenged the belief of older adults being asexual by depicting them as sexual beings. Paradoxically, at the same time, older adults are encouraged to remain physically attractive, to maintain sexual activity (Wada et al., 2015). However, perceptions of both asexuality and over sexuality and ageist stereotypes can negatively impact older adults’ sexuality (Berdychevsky & Nimrod, 2017). The same goes for the high accent on sex in Western culture and “active aging” (Katz, 2000), especially when one no longer shows sexual interest (Soares & Nazareth Meneghel, 2021). A study that sought to understand older women’s experiences in new romantic relationships showed that none of the women interviewed perceived aging as negatively impacting their sexuality. Sex was not necessarily as important in later life as it was previously, but was an important part of their relationship, being associated with intimacy and closeness (Watson et al., 2017).

Older adults would like to be able to discuss openly sexual matters with healthcare professionals and even receive help if needed (Mahieu & Gastmans, 2015; Smith et al., 2007), but 80% of men and women noted that they did not recently discuss with healthcare professionals about sexually transmitted infections or safe sex practices (Farrell & Belza, 2012). Still, besides the reported lack of knowledge and training regarding sexuality in later life (Gewirtz-Meydan et al., 2020; Haesler et al., 2016) healthcare professionals perceive sexuality as private, therefore offending if discussed. Moreover, they believe that within primary care, sexual health is outside their scope of practice (Haesler et al., 2016).

Asexual stereotypes could therefore lead to two types of reactions: acceptance or rejection of the stereotype. Older adults both face and internalize these stereotypes. As it is hard to draw a clear line between stereotypes and observations, possibly asexual stereotypes influence, on one hand, perceptions of sexuality in later life and, on another hand, sexual behavior of older adults (Sinković & Towler, 2019), but an interdependence between these factors may exist as well.

We imply that, undoubtedly, these views of sexuality in later life reflect on policies and research, which influence back society’s view. The number of studies done worldwide on the sexuality of older adults, which include just people older than 65, is very low, as seen in this review. This leads us to seriously question the interest of policymakers, researchers, and healthcare professionals regarding older adults’ sexuality. Inconsistencies between policy and the fieldwork, such as whether there should be discussions about sexual activity in later life between healthcare professionals and older adult patients, highlight the need for more research on this matter.

We hypothesize that the dearth of research on sexuality in old age is due to the lack of aging sexual health policies before 2013, as well as the uneasiness of communication of healthcare professionals with older adult patients regarding aging sexuality. For the moment, we identified only four policy documents that discussed the actual problems in sexual health and aging. They set a few objectives, including the promotion of sexual health and the rights of older people and the education and training of healthcare professionals on sexual health. However, these have appeared many years after the adoption of the Programme of Action at the International Conference on Population and Development (ICPD) held in Cairo in 1994. This program emphasized the fundamental role of women’s interests in population matters and introduced the concepts of sexual and reproductive health and reproductive rights.

Treating older adults as asexual could be seen as “sexual neglect” (Leading Practice to Counter the Mistreatment of Older Adults et al., 2017) which is a violation of sexual rights and could be considered sexual violence against older adults (Nobels et al., 2020).

Limitations and future research

The main limitation of this literature review is the fact that the process employed is not strictly reproducible. Whereas a systematic review summarizes study findings, a critical interpretive synthesis adopts a dynamic path, from formulating the research question to critically synthesizing the findings and bringing new perspectives. The insights brought by this analysis and the theory development from the existing literature and policies should prevail, regardless of the difficulty in reproducibility.

This review did not focus on LGBT older adults, nor on those being institutionalized. Future research could be realized regarding these groups. Futures studies should analyze different age categories within the frame of older adults.

For a better understanding of sexual expression in later life, more studies should consider the importance of sexuality for each participant and his or her sexual frequency in the past and at the moment of the study. If we limit our questioning to sexual behaviors and frequency of intercourse, we risk overlooking the importance given by older adults to sexuality in later life and misunderstand it. Future research should focus on the sexual needs of older adults and should go beyond sexual activity, including affection and intimacy. This could serve as a basis for practitioners, who would be prepared to offer tailored care to older adults. Future research on sexuality in later life should be done on the sexual needs of older adults who present cognitive decline (Pinho & Pereira, 2019). The results of this CIS call on the need for the urgent training, education, and information of practitioners on aging sexual health. While for the moment, policies on sexual health mention older adults, future public health policies should be dedicated to the “oldest” old population and their sexual health.

Conclusions

Our CIS summarizes the research that has been done on community-dwelling adults older than 65 regarding sexuality. Our study confirms that older adults engage in sexual activity and in other expressions of sexuality as defined by the WHO (2010). It also brings up the stereotypes linked to later life sexuality and the uneasiness of healthcare professionals to communicate on aging sexuality with older patients. The low number of studies done on sexuality after the age of 65 highlighted the scarcity of research on this topic, from a positive public health approach. While questioning the public health policies, we found only four documents mentioning aging sexuality, starting in 2013. Our critical analysis could serve as a basis for practice, research, and policy to focus on aging sexuality in line with older adults’ needs positively and respectfully avoiding stereotypes.

In the past 30 years, there has been a spate of public health research on sexuality. Paradoxically, this topic seems barely addressed concerning the older population, although sexual health is promoted under the umbrella of both public health and human rights. Positioning older adults as asexual could be seen as “sexual neglect,” which violates sexual rights. By refraining to see sexuality in old age as a human right, we deny its realization for older adults. Despite findings that show older adults being sexually active, sexuality in later life is still the elephant in the room, whether we refer to policies, practices, or research. This leads us to seriously question the interest of policymakers, researchers, and healthcare professionals regarding older adults’ sexuality.

Health policies and scientific research on the sexuality of older adults appear insufficient, as this synthesis suggests. We posit that society’s view of later life sexuality, reflects on practice, policies and research on this topic, which influence back society’s view. The position of public health is reflected in ageist stereotypes in society, including research, concerning the sexuality of older adults and vice versa. Consequently, not addressing sexual health through policies could lead to further under-research of this topic, which would lead further to practitioners’ less knowledge of sexuality. This could also contribute to a lack of tailored care for older adults’ sexual needs. Healthcare professionals need training on aging sexuality, to optimize their communication on this topic with older patients. Future public health policies should focus on older people and their sexual health.

Funding Statement

C.V.’s contribution to this work was supported in part by the Research Foundation—Flanders (FWO) Postdoctoral Fellowship funding scheme under Grants 12C0616N to C.V.

Conflict of Interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.