Sexuality according to Ginsberg et al.¹ is an activity of daily living that is important for a number of older people. Despite this, Edwards² notes that within health care systems the sexual needs of the older person are often unrecognized and unmet, often as a result of negative attitudes and beliefs towards sexuality, sex and sexual desires. Many believe that these complex concepts can only be likened to youthfulness. Other factors can impinge on the individual’s ability to express freely their sexuality, for example, environmental (structure) constraints in long term care facilities may hinder an older person being able to express their sexual needs³. Some common barriers to enjoying sex as a person ages are health problems or lack of a partner as opposed to lack of desire. Little research has been carried out with respect to stereotypical ideas about sex and ageing.

Healthy people are often sexually active people and this has an impact on the quality of an individual’s life, therefore to deny an elderly person the option of being sexually active may result in dysfunction and distress. Among older adults there is an internal drive or need for sexual fulfilment⁴.

As people age the frequency in which they engage in sexual activity declines. Nevertheless, a substantial number of men and women engage in vaginal intercourse, fellatio, cunnilingus and masturbation, and some people remain sexually active in their eighties and nineties. The limited data that has been analysed demonstrates that there are some men and women who maintain sexual and intimate relationships and desires throughout their lives⁴.

Illness can seriously impede sexual activity but there is a dearth of literature regarding how illness impacts on the sexual activity of the older person. Altered pathophysiological changes often associated with the ageing process impact on sexual response in men and women, and most of the changes have a negative bearing on the person, both physically and psychologically.

The loss of a partner as a person ages is common (particularly in older women). Problems associated with the sex act may be a precursor to problems related to an underlying illness such as diabetes mellitus, a genitourinary tract infection or cancer⁵. There are a number of age-related changes in the vasculature and smooth muscle tissues involved in the erectile process as well as increased sensitivity to inhibitory signals in the smooth muscle^6,7. There are physiological changes that are associated with the menopause (these are complex); for example, a reduction in vaginal lubrication in response to a decrease in oestrogen levels. Attitudinal responses by society to postmenopausal women and their sexuality may also lead to an increase in vulnerability to depression.

Sexual problems for men can include difficulty in achieving or maintaining an erection, lack of interest in sex, climaxing too quickly, anxiety about performance and an inability to climax. For elderly women bothersome problems include lack of interest in sex, difficulty with lubrication, an inability to climax, disliking sex and pain – often felt at the vagina during entry⁴.

If problems associated with sexual activity are not treated or are left undiagnosed this may lead to depression or social withdrawal. There are also a number of medications that can result in sexual dysfunction that patients need to take for an ongoing physical or psychiatric illness. The result of sexual problems arising from the taking of prescribed medications may induce the person to stop taking them in an attempt to reduce the negative side effects related to them.

Bancroft et al.⁸ emphasize the effect of relationship factors and mental health (particularly with regard to women) as being more important predictors of sexual well-being than the physiological factors of sexual arousal and response. For a number of women (tentatively, this could also be said for some men) being in a relationship, the quality of that relationship and a partner’s sexual problems are more important than their sexual responsiveness. Bancroft et al.⁸ considered only heterosexual women in his study; further research is needed to consider the impact of relationships versus sexual responsiveness in the LGB population. Kellett⁹ suggests that counselling may allow a couple who are experiencing sexual problems to express their fears and inhibitions, with the therapist educating the couple about the normal changes that accompany ageing.

The law demands that both parties engaging in sexual relations must consent; this is equally true for the older person, who may have issues associated with cognitive impairment such as dementia. Sexual abuse is a criminal offence. Free will and capacity are germane to informed consent. It may be difficult to ascertain if a person who is cognitively impaired has the capacity to consent to sexual relationships and as such this renders that person vulnerable. There are several potential ethical and legal issues that may arise as a result of this (Mental Capacity Act, 2005). Assuming that a person with dementia cannot make decisions and consent to intimate relationships or that they are unable to comprehend the consequences of decisions associated with consent, sex is unacceptable.