One area that many health care professionals consciously or unconsciously overlook when working with seniors is sexuality. Yes, even people in their seventies and eighties actively participate in sexual activities. Somehow, when one is a senior and/or is physically challenged in some way, most people tend to think that they cannot possibly be interested in sex. Society tends to see it as a joke -- the "dirty old man'' or women who are "mutton dressed as lamb''. If as occupational therapists we can help overcome this view and see sexuality in seniors as an important need, then we are half-way to understanding our clients'/patients' problems.

A client will often ask an occupational therapist something which he or she is too embarrassed to ask a doctor. This is not too surprising as the basis of our relationship with the client is to find solutions to practical problems.

Clearly there are obvious physical changes which will inhibit sexual responses, yet there does not have to be an age limit to an active sex life.

Some major factors which will affect seniors' sexuality are: age, physical health, mental status, social situation i.e. living at home, residential care facility or hospital.

Psychological changes will affect most people as they grow older. The ability to cope with change and loss, and to adapt appropriately to them, seems to be the key to growing old happily. How seniors cope with such changes depend largely on their personalities, past life experiences and social support.

Also it is important to consider the moral attitude of this generation. This is a generation who rarely discussed sex, had little or no access to information or education, had slight knowledge of contraception and perhaps little awareness of sexually transmitted diseases. Sexual intercourse outside of marriage was seen as sinful.

This ethic of not speaking, thinking or reading about sex makes one wonder how the older generation copes with today's permissive society. Many seniors are embarrassed and shocked by the media, others see it as part of the general decline in society's morality.

There are some physiological changes in seniors which relate to sexual activity. In males there is: increased difficulty obtaining and maintaining an erection, decreased power of ejaculation, reduced volume of ejaculate, and a longer refractory period. In females there is: thinning of vaginal skin, loss of elasticity of vaginal wall, increase in time for lubrication to occur, shorter orgasmic phase and vaginismus may occur.

There is no doubt that as many couples grow older they simply close the door on the sexual part of their relationship. For those who choose to continue to have an active sex life, they should be seen as normal, healthy people. Also, remember that the non-coitus part of sex becomes increasingly important as physiological changes occur. Touching, stroking, and holding may become as fulfilling as sexual intercourse and orgasm.

After any major illness or operation there may be anxiety or doubt about resuming a sexual relationship. A worried client should always discuss the problem with his or her doctor.

Following are a few conditions to show how a client may be affected: Prostatectomy: Side effects may be impotence or retrograde ejaculation. The client should be reassured that he can still experience and enjoy orgasm.

Hysterectomy: Clients may experience vaginal dryness which can be treated with hormone replacement or local creams. Although a few clients believe that hysterectomy will affect sexual enjoyment, this is not necessarily the case.

Counselling and reassurance should give the client enough confidence to resume a sexual relationship.

Hip Replacement: Anxiety may be the greatest problem after a hip replacement operation. Sex is not taboo, however you need to be aware of the position into which your hips must not be forced and be the more passive partner. The initial six weeks post surgery are very important. Guidance on positioning and permission should be sought from your surgeon at the six week follow-up stage.

Hemiplegia: Again anxiety may be a major problem. Medical advise is essential.

Advice on positioning and taking a less active role will be useful.

Counselling will relieve the partner's anxiety that sex may cause a relapse.

Rheumatoid Arthritis/Osteoarthritis: The client may need to take a less active role. It may also be necessary for the client to take analgesics before intercourse. Try several positions until you find what is most comfortable for you. Pillows can be placed under stiff or painful joints, or women taking the dominant position can take anxiety out of the relationship. Encouragement to take time over stimulation, may mean both partners can achieve orgasm without penetration. Emphasising the importance of touching and closeness may be enough to meet the couple's needs, and may reduce `performance anxiety'.

If a couple is prepared to adapt to their physical limitations, and are able to communicate their needs and feelings to each other, then they can continue to enjoy mutual pleasure and satisfaction.

Sharon Godwin Community Occupational Therapist