ABSTRACT

Objective: To determine the sociodemographic and clinical characteristics associated with positive attitudes towards sexuality in older adults seen in the outpatient clinic of the Hipólito Unanue National Hospital from september to december, 2021. Methods: Cross-sectional analytical observational study, which included 227 adult patients over 60 years of age from the outpatient clinic of the HNHU geriatrics service attended by teleconsultation. Attitudes towards sexuality were measured by applying the Questionnaire of Attitudes towards Sexuality in Older Adults, dividing the result into positive and negative attitudes. Results: 86.3% of older adults have a positive attitude towards sexuality, the age of 60 to 79 years was presented in 73% of these patients, higher education was higher in the group with positive attitude (47%), 53.6% of the patients with a positive attitude reported having a current partner, having received educational talks increases the probability of a positive attitude towards sexuality by 3.12 times. In the bivariate analysis, there was a statistically significant association between age 60 to 79 years (RP: 1.31, 95%CI: 1.12-1.52, p<0.001), higher education (RP: 1.19, 95%CI: 1.08-1.31, p=0.001), having a current partner (RP: 1.32, 95%CI: 1.19-1.46, p<0.001), having received educational talks (RP: 1.13, 95%CI: 1.03-1.24, p=0.033). In the multivariate analysis, an association was found between having a current partner and a positive attitude towards sexuality (RPa: 1.177, 95%CI: 1.09-1.26, p<0.001). Conclusions: There is a high frequency of positive attitude towards sexuality in older adults, and having a current partner was an independent associated factor.

Keywords: Eldery, sexuality, Attitudes. (Source: MeSH–NLM)

RESUMEN

Objetivo: Determinar las características sociodemográficas y clínicas asociadas a las actitudes positivas hacia la sexualidad en adultos mayores atendidos en el Hospital Nacional Hipólito Unanue de setiembre a diciembre del 2021. Método: Estudio observacional, analítico y transversal, que incluyó a 227 pacientes adultos mayores de 60 años de consulta externa del servicio de geriatría del HNHU atendidos por teleconsulta. Las actitudes hacia la sexualidad se midieron con la aplicación del Cuestionario de Actitudes hacia la Sexualidad en Adultos Mayores, dividiendo el resultado en actitud positiva y negativa. Resultados: El 86,3% de adultos mayores presentan actitud positiva hacia la sexualidad, la edad de 60 a 79 años se presentó en el 73% de dichos pacientes, la educación superior fue mayor en el grupo con actitud positiva (47%), el 5,.6% de los pacientes con actitud positiva refirió tener pareja actual, recibir charlas educativas incrementa en 3,12 veces la probabilidad de actitud positiva hacia la sexualidad. En el análisis bivariado hubo asociación estadísticamente significativa entre la edad de 60 a 79 años (RP: 1,31, IC95%: 1,12-1,52, p<0,001), la educación superior (RP: 1,19, IC95%: 1,08-1,31, p=0,001), el tener pareja actual (RP: 1,32, IC95%: 1,19-1,46, p<0,001), el haber recibido charlas educativas (RP: 1,13, IC95%: 1,03-1.24, p=0,033). En el análisis multivariado se encontró asociación entre el tener pareja actual y la actitud positiva hacia la sexualidad (RPa: 1,177, IC95%: 1,09-1,26, p<0,001). Conclusiones: Existe alta frecuencia de actitud positiva hacia la sexualidad en adultos mayores, y el tener pareja actual fue un factor asociado independiente.

Palabras clave: Adulto Mayor, actitudes, sexualidad. (Fuent: DeCS–BIREME)

INTRODUCTION

Topics related to sexuality are largely influenced by conventional beliefs, prejudices, and stereotypes that often treat them as taboo or difficult subjects, especially when they involve or are directed towards older adults ^(1-3). Despite various studies describing how sexuality plays a fundamental role in achieving personal well-being and quality of life in this age group, society still holds attitudes that categorize older adults as devoid of sexuality. Addressing this topic remains a challenge for healthcare professionals ^(4,5).

Attitudes towards sexuality in older adults are complex to address because many people believe that sexuality diminishes, overlooking the changes associated with aging that evolve over time ⁽⁶⁾. There are few national studies on this topic, and most of them are descriptive in nature, highlighting a high frequency of positive attitudes towards sexuality in older adults ^(7-10). Other authors have suggested that age and marital/partner status may contribute to better attitudes towards sexuality ^(11,12).

Therefore, more research on sexuality in older adults is needed, as this stage of life presents constant changes in habits and behaviors for this population. Hence, this study aimed to determine attitudes towards sexuality and the characteristics associated with a positive attitude.

MATERIALS AND METHODS

Design and Study Area: An observational, cross-sectional analytical study was conducted.

Population and Sample: The population consisted of all older adults - 273 - attending the outpatient clinic through teleconsultation at the Geriatrics Department of HNHU (Hospital Nacional Hipólito Unanue) from September to December 2021. The research was conducted from September 1, 2021 to August 20, 2022.

Non-probabilistic convenience sampling was used. The sample size consisted of 227 older adult patients aged 60 years and above.

Participants who did not complete the interview, had incomplete medical records, or had cognitive or hearing impairment, or language barriers that hindered the telephone interview were excluded. All participants provided their consent for the telephone interview.

Variables, instruments, and procedures: Telephone surveys were conducted with an average duration of 15 minutes per patient. Data on age, sex, marital status, current partnership, educational level (whether or not higher education was attained), and whether they had received sexual education talks (provided by healthcare personnel) were collected. The presence of female and male sexual dysfunction was determined using the Female Sexual Function Index (FSFI-2) and Male Sexual Health Questionnaire (MSHQ), respectively ^(13,14). Finally, the Aging Sexual Knowledge and Attitudes Scale (ASKAS) test was administered to assess attitudes towards sexuality (positive or negative) ⁽¹²⁾.

As this is a cross-sectional study, selection bias has been considered since prevalent cases were worked with, rather than incident cases. However, it should be noted that all patients were regularly treated at the same hospital, and the questionnaire was administered by the same person following the same protocol.

Data Analysis: The data was organized in Excel 2016 and analyzed using SPSS version 26. Pearson's chi-square test was used for comparison and determination of association between qualitative or categorical variables. Prevalence ratio (PR) and 95% confidence interval were calculated. Additionally, for the variables that were found to be significant (p<0.05), multivariate analysis was performed, and adjusted PRs were obtained.

Ethical Considerations: Authorization was obtained from the Head of the Department of Medical Specialties at HNHU (Hospital Nacional Hipólito Unanue) and the Ethics Committee of the Faculty of Medicine at Universidad Ricardo Palma. Verbal consent was obtained from each patient for the use of their data in the research results. To ensure confidentiality, data was protected using codes and stored with backup copies and access restrictions, allowing only the researcher to analyze the data.

RESULTS

Table 1 describes the general characteristics of the patients included in the study. 86.3% had a positive attitude towards sexuality, with an average age of 75.63 years, and 67.4% were below 80 years old. 65.6% were women, and 56.8% had non-higher education. 50.2% were widowed or divorced, 40.9% were married or cohabiting, and 46.7% reported having a current partner. Sexual dysfunction was present in 68.4% of women and 71.8% of men. Finally, 71% stated that they had received educational talks on sexuality.

Table 2 presents the analysis of sociodemographic and clinical factors associated with attitude. Age was higher in patients with a negative attitude compared to the group with a positive attitude (81 and 74.8 years, respectively, p<0.001). Similarly, it is observed that the age range of 60 to 79 years is associated with a positive attitude (PR: 1.31, 95% CI: 1.12-1.52, p<0.001). Sex was not a factor associated with attitude towards sexuality. Male sex was present in 36.7% of those with a positive attitude and 19.4% in the group with a negative attitude, but it did not show a significant difference to be considered an associated factor (p=0.058). Regarding education level, higher education was higher in the group with positive attitudes towards sexuality (47.4%) and was an associated factor (PR: 1.19, 95% CI: 1.08-1.31, p=0.001). Being married or cohabiting was present in 46.9% of those with a positive attitude, and a significant association was found (p=0.014), while being widowed or divorced was a protective factor (PR: 0.77) in relation to a positive attitude, meaning more negative attitude. Having a partner increased the probability of having a positive attitude towards sexuality by 1.32 times (PR: 1.32, 95% CI: 1.19-1.46, p<0.001). Female sexual dysfunction (p=0.067) and male sexual dysfunction (p=0.513) did not show a significant association. Male sexual dysfunction increased the probability of a positive attitude by 1.05 times, but this increase was not significant.

Finally, receiving educational talks is a factor associated with having a more positive attitude. 31.6% of the group with a positive attitude received them compared to 12.9% of those who did not receive them. There were more people with educational talks in the group with positive attitudes, resulting in a prevalence ratio of 1.13.

Table 3 presents the multivariate analysis, where age 60-79 (adjusted PR: 1.048, 95% CI: 0.99-1.10, p=0.058), higher education level (adjusted PR: 1.068, 95% CI: 0.98-1.16, p=0.126), being married/cohabitating (adjusted PR: 1.006, 95% CI: 0.99-1.02, p=0.399), and receiving educational talks (adjusted PR: 0.980, 95% CI: 1.07-0.89, p=0.660) did not demonstrate being associated factors for a positive attitude towards sexuality. Only having a current partner is an associated factor for a positive attitude towards sexuality (adjusted PR: 1.177, 95% CI: 1.09-1.26, p<0.001).

Adjusted Prevalence Ratio (APR): obtained through logistic regression constructed with the variables: age (60-79 years), education level (higher), marital status (married/cohabiting), current partner (yes), educational talks (received).

DISCUSSION

The majority of participating older adults were under 80 years old (67.4%). In the bivariate analysis, 73% of older adults with a positive attitude towards sexuality were between 60 and 79 years old, and they had a higher likelihood of having a positive attitude towards their sexuality, which was 1.31 times higher than those aged 80 and older. Therefore, as age increases, the frequency of negative attitudes also increases. In this regard, Ramos E. et al. refer to individuals between 46 and 80 years old as having a 4.12 times higher likelihood of a positive attitude towards sexuality (p=0.04) ⁽¹⁵⁾. This indicates that individuals over 80 years old would hold their beliefs and prejudices about sexuality more firmly, considering it a taboo topic. Therefore, it is more difficult for them to share their knowledge, perceptions, fears, or concerns and adopt positive attitudes towards this subject.

Regarding gender, a higher frequency of females was found in both the positive attitude group (63.3%) and the negative attitude group (80.6%); however, this result was not significant (p=0.058). Torres S. et al. report in their systematic review that most studies have a higher percentage of females than males ⁽¹⁶⁾. This would explain the higher frequency of females. It has also been reported that women have greater ease in contemplating issues related to their sexuality and adopting a better attitude towards it, despite having lower rates of sexual activity compared to males ⁽¹⁷⁾, and they are more likely to inhibit their sexual desires ⁽¹⁸⁾.

Older adults with higher education have a 1.19 times higher likelihood of having a positive attitude (PR: 1.19, 95% CI: 1.08-1.31, p=0.001), which strengthens the idea that higher education significantly influences the attitudes adopted by older adults. Hernández M. et al. state that higher educational levels have a direct influence on the positive attitudes of older adults, as they provide them with more knowledge about sexuality, allowing for better development within their relationships ⁽¹⁹⁾. Access to more educational resources on sexuality enables the adoption of better attitudes. The less knowledge one has in this regard, the more likely it is that negative attitudes learned from the environment will prevail ⁽¹⁵⁾.

Of the adults with a positive attitude, 46.9% were married or in a cohabiting relationship, which, although higher than the group with a negative attitude, was not significant (p=0.053). Similarly, nearly 90% of those who expressed negative attitudes were widowed or divorced. Melguizo E. et al. agree in pointing out that around 60% of older adults with poorer attitudes towards their sexuality reported being widowed or separated ⁽³⁾. Torres S. et al. state that widowed women have negative attitudes towards sexuality as they associate it with the duty of procreation with a partner, in addition to being mostly influenced by their religious doctrine ⁽¹⁶⁾. García F. et al. state that being married or in a cohabiting relationship provides stability, which in turn leads to a higher degree of intimacy and reinforces positive attitudes towards sexuality ⁽²⁰⁾.

The majority of participants with a negative attitude did not have a current partner, indicating that the presence of a partner could improve attitudes towards sexuality (PR: 1.32, 95% CI: 1.19-1.46). Morell V. et al. reported in their study that only 47.1% of participants reported currently having a partner, and having a partner was associated with 2.66 times higher chances of having better attitudes ⁽²¹⁾. Older adults with a partner adopt better attitudes towards their sexuality, as the level of intimacy provided by these relationships allows them to confront the various physiological limitations that arise with age. It is also considered that being in a romantic relationship increases desire and sexual activity, leading to a better perception of the topic and greater ease in confronting prejudiced views that may have been ingrained throughout life ⁽¹⁸⁾.

Most of the perceived limitations experienced by this population, both physical and psychological, are related to the term "sexual dysfunction" (SD), which also has distinctions based on gender ⁽¹⁵⁾. Within the study, 71.8% of women admitted to experiencing SD at that time, with no significant difference compared to men, where it was present in 68.4%

The absence of this dysfunction represents a 1.15 times higher probability of having a better attitude towards sexuality (95% CI: 0.99-1.31) in women and 1.05 times (95% CI: 0.93-1.18) in men, although these results were not significant, indicating an inverse relationship between the two variables. Hernández M. et al. state that SD manifests in multiple forms and involves various factors encompassing physical, psychological, emotional, cultural, and social aspects, all of which influence the attitudes that older adults adopt towards their sexuality ⁽¹⁹⁾. Gharibi et al. agree and reaffirm that SD involves variables such as physical limitations, decreased sexual desire, reduced genital lubrication, and the presence of chronic diseases (and polypharmacy), which can diminish sexual desire and lead to negative attitudes ⁽⁾. Linares et al. point out that over 70% of women with SD lose motivation with their partner, while only 20% of men indicate a similar situation, explained by the fact that men tend to focus their satisfaction on maintaining their sexual capacity ⁽²²⁾.

It was found that 71% of the participants reported having received some type of sexual education talk. This frequency was higher among those who had a positive attitude (31.6% compared to 12.9%) compared to the group with negative attitudes, showing association in the bivariate analysis (Prevalence Ratio [PR]: 1.13, 95% CI: 1.03-1.24, p=0.033), but not in the multivariate analysis (Adjusted Prevalence Ratio [APR]: 0.980, 95% CI: 0.89-1.07, p=0.660). Hernández M. states that less than 50% of those who showed a better attitude had received information through talks or consultations with specialists ⁽¹⁹⁾. These findings can be explained by the fact that adults over 60 perceive sexuality topics through the beliefs and social patterns they have learned throughout their lives, resulting in a challenging process of internalizing new knowledge in this regard ⁽¹⁸⁾.
Finally, it is evident that despite a high percentage of participating patients reporting positive attitudes towards sexuality (86.3%), there are different biopsychosocial characteristics that significantly influence prevalence within the older adult populations ⁽¹⁹⁾.

CONCLUSION

In conclusion, there is a high frequency of positive attitudes towards sexuality among older adults. Having a current partner did show a significant association with positive attitudes towards sexuality and is an independent factor. It is recommended to expand the demographic characteristics in further studies, taking into account differentiation based on gender, increase the dissemination of knowledge and information about sexuality, considering the demographic characteristics of older adults. Finally, a multicenter study is recommended to further expand the research.

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