Public Health
Realities in the Sexuality of the Cuban Elderly Realidades acerca de la sexualidad en el adulto mayor cubano
Aida Rodríguez Cabrerai1, Luisa Álvarez Vázquez2, Giselda Sanabria Ramos3
(1) Doctor in Economic Science, Associate Professor of the Escuela Nacional de Salud Pública de Cuba.
(2) Doctor in Economic Science, Assistant Professor of the Escuela Nacional de Salud Pública de Cuba and Full Investigator of the Instituto deEndocrinología de Cuba.
(3) Doctor in Health Science, Associate Professor of the Escuela Nacional de Salud Pública de Cuba .
Original aricle received February 20, 2015
Accepted August 10, 2015
CORRESPONDING AUTHOR: Dr. Aida Rodríguez Cabrera. Escuela Nacional de Salud Pública. calle 100 (Ave.San Francisco), número 10132 entre Perla y E. Altahabana, Municipio de Boyeros, zona urbana en La Habana, Cuba, E-mail: aidarc@infomed.sld.cu
Abstract
Objective: To identify references on the main sexuality characteristics of people aged 60 or over.
Method: An analysis of the contents of published articles was carried out in Cuban and foreign scientific publications from the year 2000and onward. Information was obtained from Yearbooks, InternationalConference Reports and works considered as classical in the subject.
Results: Population ageing and sexuality are not properly consideredby health systems. There are only a few references that exploresexuality in the elderly and his aspirations, feelings, and ways ofthinking on his healthcare and, more specifically, sexuality needs.Intimacy within an elderly couple is generally disregarded from thesocial and family points of view.
Conclusions: The assessment of sexual activity in the elderly lacks a multidisciplinary approach since most of the predominating criteriaare permeated by cultural influences, taboos, myths and habits thatnegatively influence it. Evidence points out to the existence of sexualactivity and dysfunctions among the elderly, which indicates the needfor a healthcare staff that has is properly trained for approaching anyissue related to this activity of life. The determining role of the healthsector in this field as coordinator of all the sectors and actors related tohuman sexuality and the ageing process, is not fully appreciated.
Key words: Sexuality, elderly, sexual and reproductive health
Resumen
Objectivo: Identificar referencias sobre las principales características de la sexualidad en personas de 60 años y más. Metodo: Se realizóun análisis de contenido de artículos publicados desde el año 2000en revistas científicas cubanas y extranjeras. Se obtuvo informaciónde Anuarios, informes de Conferencias Internacionales y librosconsiderados clásicos en el tema. Resultados: El envejecimiento de lapoblación y la sexualidad no está bien considerada por los sistemas desalud Hay pocos referentes donde se exploren en el adulto mayor susaspiraciones, sentimientos y formas de pensar sobre sus necesidadesde atención en salud y especialmente sobre sexualidad. La intimidadde los adultos mayores, generalmente no es tomada en cuenta desdeel ángulo social y familiar. Conclusions: La valoración de la actividadsexual en el anciano carece de un enfoque multidisciplinario, puespredominan criterios permeados por influencias culturales, tabúes,mitos y hábitos que influyen de manera negativa en ella. Se evidenciaque existe la actividad sexual en los ancianos y la presencia dedisfunciones sexuales, lo que habla de la necesidad de que el personalde salud que los atienda posea conocimientos adecuados en esta esferade la vida. No se aprecia el rol determinante del sector en este campo,como coordinador de todos los sectores y actores que tienen que vercon la sexualidad humana y el proceso de envejecimiento.
Palabras claves: Sexualidad, adulto mayor, salud sexual y reproductiva
Introduction
Population ageing is one of the most significant trends of the 21st century as a process with a major impactand scope in all the aspects of society1. The decreasein fertility and mortality rates, and the longer lifeexpectancy at Barth are responsible, to a certain degree,of the sustained increase of the population aged 60or over in most countries.2 This process has stronglyemerged in Cuba and it can be said that the country'spopulation in currently aged.
Ageing is a achievement of development for humanity since people enjoy longer lives, with a life expectancyat birth of over 80 years in 33 countries while, only fiveyears ago, this had only been achieved in 19 countries.3, 4.
The other countries in Latin America have followed this trend. In the last decades, the region has witnessed anincrease in life expectancy and a decrease in fertility,leading to an increase in the number of elderly (60-79years of age) and very elderly (80 years and over) persons.It is estimated that by 2025-2050, the ratio of populationbelonging to these two groups will be of 14 % and 23.4%, respectively, and that 80 % of this population sectorwill be living in developing countries by the middle of thiscentury.5-7 Within this context, Cuba ranks as the secondmost aged country in the region, followed by Uruguay,and it is expected to be the most aged country in LatinAmerica by the year 2025, with 26 % of its populationaged 60 or over.8, 9 The magnitude reached in this senseand the speed at which it has transformed the Cubanpopulation pyramid represents a major concern for thenext few years that poses key challenges for the country'seconomic and social life and for its society at large.
The consequences of ageing are directly linked to changes in the social and economic structure in general,and specifically to population health picture, availabilityof labor resources, social security, family composition,increased demand of geriatric and gerontology services,and a important increase in health expenses, togetherwith other basic factors of the country's social and economic dynamics.10-12
The current conceptions of health favor its thoughtful assessment from an adequate perspective. Such isthe case of the reproductive health, accepted in 1994at the International Conference on Population andDevelopment, same which had been growing for severalyears in many countries and that was approved by mostof them at that same occasion.13 This concept includessexuality, particularly in Cuba, where it is referred to asSexual and Reproductive Health (SRH), and to which theentire population is entitled, from birth to late life stages.
Works on elder populations related to the frequency, cause, risk factors, and evolution of the various diseasespresent at this life stage are frequently found. However,only a few focused in finding positive elements that favorwell-being in the elderly, particularly in regards to thesexuality characteristics typical of this age.
The World Association for Sexual Health14 stresses the need to address sexuality in the elderly when it statesthat sexual pleasure must be considered as an essentialcomponent of total health and well-being. It alsoemphasizes that the sexual rights of all the populationsectors must be recognized, promoted, guaranteed andprotected.
The current situation in Cuba regarding its ageing degree and the progress achieved in the field of health, calls forrenewed approaches to addressing the sexuality needsa nd orienta ti ons of th e el derl y, and for a dequa telytrained healthcare professionals. Only in a few caseshas there been some deepening into the perceptions,criteria, and behaviors of the elderly, as well as into thefeelings and actions related to their intimate life andtheir consequences, both for them and for society. 15
Most elder persons believe that their sexual life has ended which is obviously a prejudice, an erroneouspreconception, since all the elderly that enjoy a relativelygood health, are capable of enjoying sexual activitiesuntil a very old age.16
This work is aimed at identifying references on the main characteristics of sexuality of the population aged 60 andover. Some aspects of population ageing and the healthsystem in Cuba are also analyzed.
Materials and Methods
An analysis of the contents of papers on the subject published since the year 2000 and onward was carriedout which comprised a literature review of all the Cubanand foreign scientific journals included on the databasecompilers of CUMED, EBSCO and HINARI. Regarding theCuban serial publications, those that accept works on thesubject were reviewed, including those on Public Health,Integral General Medicine, Endocrinology, and Sexualityand Health. Information was also obtained from Cubanstatistical yearbooks published by the Dirección Nacionalde Estadísticas (National Statistics Department) (years2012-2014) , the reports on International Conferences,mainly the Population and Development Conferenceof El Cairo, and from the books considered as literatureclassics in the subject of sexuality, regardless of theirpublication date.
All the articles published in the above journals were included in the search if they were related to thefollowing analysis categories: "elderly", "old age","population ageing", "sexual and reproductive health","sexual satisfaction", and "perception of satisfaction"
Using this procedure, papers were found that complied with the search terms. The information gathered fromeach work was grouped to determine informationregularities on the subject of study.
Sexuality in persons aged 60 and over.
Old age is and has been a significant social phenomenon. Ageing and the image of old age, take the individualsby surprise. The perception of old age is generallynegative, people try to evade old age and, when it is notpossible anymore, they strive to mask at least its signs,since complaints are more frequent than satisfactionsin regards to this life stage. Besides, old age has beenrepresented or linked to an image of disease, infirmityand disability, i.e., the carrier of catastrophic, rigid,inactive, and dependent stereotypes, where sexuality isone of the most diminished, or even absent, activities.
In old age, multiple social factors have an influence and sometimes lead to serious disturbances in the dailylife of the elderly. Losses, either physical or spiritual,the absence of supportive confidants and inactivity,considerably contribute to a negative self-esteemwhich, coupled with the maladjustment to retirement,dissatisfaction with the social roles imposed, andmaterial living conditions of these groups, undoubtedlygenerate the fear to transit this stage of life and hindersocial and sexual relationships. Likewise, physical andbiological changes increase the vulnerability of thesegroups to isolation and disability, where indifferencetowards sexuality occupies a relevant position. 15-17Ageing contributes to a reduced effectiveness ofsensorial and motor functions, to a slowing of reflexesand a diminished memory. Despite the progressive lossof muscle elasticity and the slowing metabolism, it hasbeen shown that old age is not a disease, since manylong-living people (over 90 years of age), have neversuffered signs of dementia or other disabilities thatlimit their daily activities.18-19 This indicates that old ageis conditioned by individualized ageing processes.20However, on many occasions ageing is considered asa synonymous for decline and the changes related tosexual activity are perceived as the ending stage ofsexuality.
Besides, it must be taken into account that social age determined the individual role that a person shouldperform in society, which is particularly true for the elderly.This classification may be perceived as discriminating,since it does not consider the personal skills and attitudesapplied to solving daily life challenges.21 The authors ofthis paper consider that, from this approach, sexualityis not valued socially, since it is conceived as somethingforeign to this population group.
All of the above, allows stating that the vision of population ageing and sexuality is neither properlydefined nor considered by health systems, since it is notconceived within the healthcare needs of this populationgroup, both from the assistance point of view and fromthe promotion of and education on sexuality in theelderly.
Sexuality in the elderly in an ageing Cuba.
Within the context of developing countries, Cuba's demographic dynamic has displayed an almostunique behavior, characterized by a most advanceddemographic transition, with a very low or non-existentpopulation growth, fertility indexes quite below thereplacement rate, 22 low child / infant mortality rates,high life expectancy, and a negative balance in externalmigration. This combination of factors has led to amarked ageing process which, in accordance to manydemographers, is irreversible. 23
According to demographic expectations, Cuba will be among the most aged countries of the world by the year2050, with 39.2 % of his inhabitants aged 60 or over. Bythat year, the mean age would be of 52 years, whichwould rank it 8th among the countries with the highestdependency index, with a predominance of old and veryold persons.24
In Cuba, the distribution of the main health components per province and territory shows a clear trend towardshomogeneity, an achievement resulting from theincrease in the quantity of trained human resources, ofhealth units, as well as of improving the specializationlevels and the technological development of services.However, in the current Cuban society, there existyet some sexuality-related elements within the socialcontext that are permeated by archaic conceptions thathave not evolved sufficiently.
Demographic ageing represents a paramount challenge for the health sector, responsible for promoting andproviding quality healthcare to the elderly. In this regard,sexuality is excluded despite being an important aspectof emotional and physical health, and it must be giventhe due priority and importance it deserves. Hence,strengthening the scenarios and actors involved at allthe levels of the Cuban government and society is amost relevant need, since this will help design strategiesthat offer the adequate services to the elderly, includingthose related to sexual health.25
For example, in the medical practices, the sexuality of elder men and women is not often examined by thehealthcare staff, as if asking exclusively for the symptomor sign that motivates the visit, was the only importantor necessary thing. Even in the case of any mention ofsexual dysfunctions by the elder patient, the answerin most cases is usually "it is typical of old age", hencestrengthening the attitude in the elderly to not valuehis sexuality. Another element that is linked to this issueis that sexuality is not included in the training of thespecialists that take care of this population sector, sucha geriatricians, gerontologists, family physicians andnurses.26'27
An important aspect on which there are limited references is the non-existent exploration of the elderperson aspirations, feelings and ways of thinking inregards to his healthcare needs and particularly, in suchan intimate area as his sexuality. It would be favorablethat this approach is considered when preparingprograms and establishing priorities that address theprinciples of equity, effectiveness, and efficiency that thepresent time is requiring for the elderly.
Some references on old age sexuality
The results show that both in Cuba as in other countries, old age sexuality is mistreated, not well known andleast understood by society, by the elderly themselves,and by the professionals or staff involved in the care ofthis population group. Even though the myth that elderpersons themselves are neither interested nor capable ofengaging in sexual activity is gradually changing, the dayis still far when a full knowledge of geriatric sexuality isachieved. Though human beings are engaged in sexualactivities from the moment they are born to the day theydie, it is well known that the manifestations of sexualityvary over time.28
A study conducted on sexuality and ageing showed that respondents answered that the main inconvenient insexual function experienced by men is delayed erection(erectile dysfunction) (41 %), and pain during the sex actin the case of women (44 %). According to the authors,said effects are due to the ageing process, in the case ofmen, and to the decrease in hormone levels associatedto ageing, in the case of women. 28 Knowing these factscould help elder persons to have access to a medicaltreatment that improves their condition.
There are also references on how the ageing process, in men and women, involve both internal and externalchanges. Men could have a diminished pre-ejaculatoryfluid and lower ejaculate force. There is also a reductionof sexual libido for multiple reasons, though mainly fora decrease of the testosterone produced at the testiclesand to factors such as alcoholism and debilitating chronicdiseases. In women, menopause plays an important rolein sexuality. In many women, the end of fertile life leadsto a greater sexual satisfaction since the fear of gettingpregnant is not longer present; however, in others, itpromotes a low self-esteem, insecurity, and decreasedsexual drive. The changes in physical appearance alsoplay an important role, since some women may not feelattractive enough. The characteristic estrogen deficitof menopause produces an atrophy of the urogenitalepithelium, increasing the incidence of infections andpain during intercourse.29
It was also found that, along the senescence process, sexuality still play an important role in the life ofindividuals, but they simply have fewer opportunities toexercise it. This leads to a certain sexual marginalizationof the ageing population, preventing the preservationof an adequate well-being in this so important aspectof their lives and, consequently, of their health, thoughthere are no reasons for sexual interest and practice todisappear at this specific age.30
It has been found that around 30 % of both men and women above the age of 65, have a regular sexual activityand that sexual interest still persists in a high percentageof these individuals, though the sexual act as practicedin younger ages, is not applicable as such in old age,where physical closeness and intimacy become moreimportant. Sexual activity and interest are preserved inmost elder men, while in women indifference to bothmostly prevails among women.31
According to the data of the World Health Organization (WHO), 22 % of the elderly worldwide suffer some typeof sexuality problem, in many occasions due to theprejudices, idiosyncrasy, and culture that are inseparablecomponents of it. In Cuba, though prejudices related tothe sexuality are not precisely recorded, it is estimatedthat approximately 15% of elder people have some sexualproblems, with a prevalence of males over females.28
There is evidence that the elderly rigorously accept the decisions imposed by their families and by society,decisions that are based on interests and needs foreignto them. The evidence also points out that sexuality inthe elderly is influenced by a set of factors that stand inthe normal development of the sexual life of men andwomen, including lack of understanding by the family,and that may also lead to its absolute denial.32
The authors of this paper consider that, in order to face ageing and its consequences, it is essential to expediteintersectorial and interdisciplinary coordination in theformulation of an integral population policy that includesboth the general aspects of the service the elderly merit,as well as the social approach of the sexuality, in such away that the intimacy of old age persons is taken intoaccount from the social and family perspective since,in many cases, elder persons are relegated both bysocieties and families that never consider they are alsoentitled to enjoy intimacy.
One of the priorities of the Programa de Atención Integral del Adulto Mayor (Program for the Integral Care of theElderly) of the Ministry of Public Health of Cuba33 is theimprovement of primary healthcare work through thefamily physician or other non-institutional alternativeswith the participation of the community. However,further work should be carried out in areas that couldenable the education of both family and community, forthe aim of guaranteeing that the elderly are respectedand their sexuality valued both in the family and socialcontexts. It is known that the sexuality of this specificage group is characterized by special elements which, aswell as with their feelings and aspirations, are generallynot well known or disregarded.
Conclusion
The appreciation of the elderly sexual activity lacks a multidisciplinary approach, since there is a predominanceof criteria permeated by cultural influences, taboos, andhabits that negatively influence it.
There are evidences that point to the existence of sexual activity and dysfunctions in the elderly, which suggestthat there is a need for properly trained healthcareprofessionals that have the adequate knowledge on thisarea of human life.
The determinant role is not properly valued of the health sector in this field as coordinator of all the sectors andactors involved in the sexuality of the elderly and theageing process.
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