The literature is abundant on the topic of sexuality and the aged, but there is little written on how to disseminate this information to the aged population in the community. Recognition of the elderly's special needs and sensitivities in discussing a topic that is potentially threatening is essential to an effective program. Brower and Tanner indicate that a program on sexuality that is not carefully planned to meet these special needs can be very threatening to the older adult and can interfere with the goals of the program.1 The purpose of this article is to relate our experiences in developing and leading a health teaching group on sexuality for senior citizens.
The need for this health teaching group became evident during a clinical rotation of some of our junior students. The concept of wellness is given special emphasis in our curriculum. Junior nursing students are placed in community settings to practice health promotion through teaching. During one of these rotations, two junior students became involved in a health program at a senior citizen residential hotel. Their program focused on the normal aging process and included the use of a commercially prepared videotape that supplemented their presentation. At this time, the students realized that they, as well as the tape, had omitted the entire area of sexuality. The students verbalized this observation and the residents quickly responded that they would like some information on this topic. Unfortunately, the students felt unable to give more than a few very general statements about the changes in sexuality that occur as a result of aging. The students did express the hope that some type of program could be developed for the future. As a result of this encounter, and also at the request of the activities director of this agency, we agreed to develop such a program for the following fall.
It was decided that the experience would be more appropiate for senior students since it would require some ability in leadership and group process, build on past experiences in health education, and utilize information on human sexuality. Since this activity would have to take place after the students' usual clinical experience hours, students volunteered for the project. The group was composed of five students including one RN who had returned to schoool for her BSN, and two faculty members, one from the psychiatric setting and the other from the community setting.
The following objectives were developed for the project:
1. Objectives for clients:
a. Increase information on the effects of aging on sexuality; and
b. Increase comfort level in talking about intimacy and sexual concerns.
2. Objectives for students:
a. Increase skills in use of group dynamics;
b. Increase skills in working with the elderly; and
c. Increase information and ability to use knowledge of human sexual needs.
We realized extensive prepara- tion would be necessary to accomplish these objectives. Our most important consideration was knowing that, in order to be effective in a group dealing with sexuality, the leaders would need to have a basic knowledge and awareness level of their own.2 To accomplish this, students were given a bibliography on sexuality and aging prepared by the faculty in order to gain a greater understanding of the subject matter. Students and faculty met as a group to discuss goals and strategies useful in groups, to role play and identify their own feelings, and to identify the potential questions and problems that might be encountered.
The next essential step was to establish a theme and format for the group sessions. Although we initially felt that the title should be "Sexuality in Later Years," the activities director at the residential hotel urged us to use the topic "Building Relationships" as she felt the use of the word sexuality would be too threatening to many of the residents. Since she had a degree in gerontology and seemed to have a good relationship with the residents, we agreed to this suggestion. We decided that an open group with voluntary membership would best facilitate our program. We felt it essential that participation in the group be voluntary since older people have fewer and fewer opportunities to make decisions. The students elected to convene for four weekly, one-hour sessions. It was decided that leaders would meet immediately after each session to evaluate the group process and to plan the following week's activities.
The following content was identified as the basis for the program:
-Session 1: introduction and establishment of an environment conducive to building relationships.
-Session 2: discussion of friendship; one's needs for friendship; desirable characteristics of a friend.
-Session 3: discussion of intimacy; the need to feel wanted and loved; ways of fulfilling intimacy needs.
-Session 4: Discussion of changes in sexual response and needs of the elderly. Recapitulation and termination of the group.
While this content was appropriate for the group experience, we recognized the need for flexibility. While it was essential to have planned content for each session, it was necessary to anticipate individual as well as group needs.
For the first session about 35 residents were in the designated room waiting for us when we arrived. The composition of the group varied in sex, age, and ethnic background. While the group members were all "elderly," we recognized that this was a heterogeneous group that was fairly well divided between those of early old age and those of advanced old age.3 Female participants outnumbered male participants at a ratio of approximately four to one. Participants' ethnic background varied widely from those who were born and raised in America to those who immigrated to America in their younger years but still held securely to their ethnic roots.
The group leaders convened the meeting by making introductions, describing the purpose of the total program and the structure of the group session, including the length and format of the meetings. Making an explicit contract seemed especially important since we sensed termination might be difficult for us and possibly for the residents also.
We began the first session by showing the film "The String Bean."* The film was chosen because its theme related so well to the isolation and need for intimacy experienced by the elderly, and also because of its availability at no cost through the local public library film consortium. At the close of the film, we divided into two discussion groups, recognizing that smaller groups would maximize the hearing and understanding of each member of the group.4 Additionally, each member was requested to introduce himself or herself. Simultaneously, a student made out and presented that participant with a name tag. This process provided a sense of intimacy within the forming groups. For the remainder of this first session the student leaders attempted to keep the focus of the discussion on the theme of the film, friendship and devotion. We ended the hour with the reminder that we would return the following week to continue these discussions.
We wanted to take advantage of opportunities to utilize touching in these sessions because Burnside3 states that the use of touch with the elderly cannot be overemphasized. We demonstrated various exercises and experiential games to the students in our planning sessions, but they opted not to use them as group strategies, perhaps finding them too threatening. Since the primary task of late adolescence and early adulthood relates to solidification of identity and development of intimate relationships,6 it is reasonable to assume that touching can be a source of potential anxiety to students in these age groups.
We were uncertain about the reactions of the residents to the first evening, but found that many returned for a second meeting. We wondered if they were motivated through loneliness or curiosity. Problems in group management emerged that night. One resident monopolized the group, another ridiculed the comments of a peer. The students' experience as group leaders was limited; faculty needed to intervene not only to salvage feelings within the group, but also to model effective group facilitation techniques for the students. Burnside5 warns many elderly are prejudiced and that mixed groups may create some tension. She suggests that group leaders should expect to deal with resentments and hostilities of members.
At the close of the meeting some group members lingered on, wanting to continue conversations and discussion, to shake hands, and to receive individual attention. We recognized the importance of this opportunity to ackowledge variations of individual needs in group participation.5 As a result, time for pre- and post-meeting greetings became an important part of each meeting.
The third meeting focused on intimacy, particularly individual needs for and ways of expressing this. The setting for this meeting was appropriately intimate-we gathered around a table in a cozy library. Disclosure of feelings seemed easier for all this evening. The concerns brought forth by the residents revolved around the young and the old relating to intimacy; acceptability of public show of affection, couples living together without the benefit of marriage, and the elderly's need for companionship with or without sexual relationships.
We noted about ten "regulars" attended this meeting with perhaps ten others gathered on the periphery. Some residents consistently preferred to sit a few feet away from the group-close enough to check out what was going on but not close enough to have to actively participate. We were aware of people's differing needs in feeling a part of the group and felt it was important to allow this flexibility in their participation. This meeting closed with the students announcing that the final session would focus on sexuality and aging.
We arrived the final evening to find our meeting place filled with residents! Already the "regulars" were arranging the chairs in a circle, but as more and more people arrived, we had to make a second row. Again we had chosen an intimate meeting room, recognizing the need to provide some sense of safety in the surroundings, but the room was soon filled to overflowing and there were many new faces. The students initiated the meeting with didactic material they had prepared on the effects of aging on sexuality including myths, misconceptions, and facts. They then opened the floor to discussion. The reactions were as varied as ever, some tentative, some vociferous. One person expressed anger and dismay that the subject of sex even be discussed in mixed company; another resident gave an impassioned soliloquy on the beauty of intimate relationships and feelings. Another resident, in an aside, stated, "I read it is okay for a young man to masturbate." We assured her that masturbation has no harmful effects. Since some of the residents seemed genuinely shocked at the topic of the evening, one faculty member asked a resident who had become a "regular" whether people had come to the meeting not knowing what the discussion focus was for the night and were inadvertently caught in an uncomfortable situation. "To the contrary," she replied, "they, came because of the topic!"
An active discussion was terminated at the hour's end with the students expressing thanks to the residents for their participation and interest. Spontaneous conversations after the meeting terminated were once again excellent opportunities to discuss feelings and thoughts perhaps unexpressed in the meeting. One gentleman, a double amputee and a "fringe regular," questioned a faculty member, "How about after an MI, it's not OK to have sex, is it?" The faculty member responded with the reassurance that for most people sex can be resumed after a coronary.
In evaluating the complete program, we feel that we met all our objectives. The participating students had an opportunity to apply theory of group process and each week they demonstrated increasing ability to facilitate interaction within the group. Through these interactions the students became more aware of the special needs, perceptions, and interests of the elderly. The residents received new information about the effects of aging upon their sexuality. While the responses of the residents were varied as to the purpose of the information, they did begin to develop an ability to discuss sexuality.
We considered the program a success and feel that our strategies were appropriate. However, as a result of the insight gained from the experience, we would make the following recommendations for repeating such a program.
1. The students participating in a program on sexuality should have completed a course on sexuality. We feel that students need to have an opportunity for their own selfexploration of their sexuality to be more effective facilitators. While our students did do readings on their own, it would have been helpful for them to have had a similar group experience prior to being a group leader.
2. The group should be closed after the first session. While it is desirable to let the elderly have a choice in group participation, more stable group membership is needed to create an intimate, trusting environment.
3. The physical environment should create an atmosphere of intimacy. It is important that the meeting place be in a quiet, calming, and comfortable room. Outside noises greatly inhibit group process.
4. The administration must be in support of the program.3 While the activities director of the resident hotel asked us for the program, we frequently met with subtle hindrances. The program did not get well publicized, the meeting room would not be set up, and another meeting was scheduled directly after ours, all of which decreased resident participation.
5. A health teaching group on sexuality should meet at least six sessions with definite topics for each session. The groups need to meet long enough for participants to feel comfortable with each other. At our fourth and final session, we were j ust getting to know each other before we had to terminate. Also, strategies need to be clearly publicized to avoid any hidden agendas.
6. Strategies should include opportunities for touching. There are several games that can be used to help participants feel comfortable with touch. While our students felt uncomfortable with touch due to their own developmental level, the elderly need touch as a part of intimacy.
7. An effective follow-up procedure is necessary. As a method of follow-up to our program, we left a box in which the residents could place comments and questions. To date we have received no responses. We now feel a more effective method would have been to make ourselves physically available to the participants at an appropriate interval of time after the conclusion of the program.
While we did have some problems with our program, it was, on the whole a very satisfying and rewarding experience. The students exhibited a genuine and enthusiastic approach to this group which was quickly absorbed by the residents. The residents were most appreciative of the time and effort that was devoted to them. It was rewarding to see several members of the group wearing their name tags at each session; they truly fostered a sense of belonging. It was also interesting to note that a number of residents were able to participate just through their physical presence. We feel that the range of the topics discussed was indicative of the residents' interests and needs in the topics of intimacy and sexuality. We hope that other nurses will be able to assist the elderly to recognize these needs regarding sexuality and will participate in similar health teaching programs.
- 1. Brower HT, Tanner LA: A study of older adults attending a program on human sexuality: A pilot study. Nurs Res 28:36-59, 1979.
- 2. Mims FA: Model to promote sexual health care. Nurs Outlook 2:121-125, 1978.
- 3. Butler R, Lewis M: Aging and Mental Health, 2nd ed St Louis, CV Mosby, 1977, pp 4-5.
- 4. Burnside IM: Overview of group work with the aged. J Gerontol Nurs 2:14-17, 1976.
- 5. Burnside IM: Formation of a group, in Burnside IM (ed): Nursing and the Aged. New York, McGraw-Hill Book Company, 1976, pp 197-213.
- 6. Erikson E: Childhood and Society, 2nd ed. New York, Norton, 1963, 423-424.