OLDER ADULTS’ SEXUALITY: EXPERIENCES OF HEALTH PROFESSIONALS AND AGED INDIVIDUALS

Objective: to verify the experiences of health professionals and aged individuals related to older adults’ sexuality. Method: a qualitative study conducted from March to April 2021 with 23 health professionals and 12 aged individuals treated in Primary Health Care in Queimadas/PB - Brazil. A questionnaire and an interview were used, whose data were processed in the IRAMUTEQ software. Results: text corpus with 35 texts and 131 Text Segments, which equals to 71.2% retention, giving rise to five classes, of which classes one and four are related to the population of older adults. In turn, classes two, three and five are assigned to the health professionals. Conclusion: the need to inform and educate older adults in terms of health was evidenced, empowering them with knowledge, changing pre-established conceptions about sexuality; as well as to train the professionals to discuss and work on the theme. The importance of health education as a strategy to improve older adults’ quality of life is emphasized.


INTRODUCTION
Sexuality accompanies human beings in all the life stages and, in this evolution, it is embedded in the aging process as an indicator of older adults' quality of life. In this context, it is up to health professionals to monitor the changes that occur in this process, associating scientific knowledge with the professional practice, in order to encourage older adults to play a proactive role in society. However, the importance of highlighting the predominant unfamiliarity of health professionals concerning sexuality at this life stage is emphasized, that is, discussions about sexuality are not well conducted when it comes to older adults 1,2 .
In the aging process, older adults' sexuality is accompanied by changes in the body, in the way of thinking and acting, that is, in the aging process there are physiological changes, alterations in the body, biological manifestations, functional modifications and greater vulnerability to pathological processes, which influence the way sexuality is experienced 3,4 . Thus, older adults are faced with social stereotypes such as the current cult of beauty, joviality and the perfect body idealized and encouraged by society, the Internet and the media, that can influence sexuality, in addition to how older adults absorb the changes of the aging body with the onset of diseases, changes in self-image, delayed sexual desire and reduced libido 5,6 .
In this phase, sexuality is still permeated by myths and preconceptions, as it is believed that it is exclusively linked to young people, attributing it as an immoral and uncommon activity in aged individuals 7 . According to the literature, aging does not mean that sexuality will be interrupted; however, society still relates older adults to asexual beings. This implies certain weakness in the care provided by health professionals and potentiates vulnerability of the aged population.
In this aspect, the approach to older adults' sexuality should be part of the health professionals' consultation routine, in promotion and assessment of older adults' quality of life.
The scarce preventive practice of discussing sexuality during the consultations, as well as the reduced value attributed to the topic is related to professional training and to sociocultural taboos 7 . In addition to that, due to the continuous growth of the aged population, there is lack of studies that address the sexuality of these individuals; thus, knowing the experience of older adults' sexuality in the contexts of health professionals and older adults themselves becomes relevant for enabling a break from pre-established concepts and taboos.
Considering the above, the study objective was to verify the experiences of health professionals and aged individuals in relation to older adults' sexuality.

METHOD
This is a qualitative study linked to the project entitled "Innovative Policies, Practices and Technologies in Older Adults' Health Care", carried out from March to April 2021 in the municipality of Queimadas, Paraíba.
The study sample was for convenience and was divided into two population groups, the first of which was made up of 43 health professionals working in Primary Health Care in the aforementioned municipality, with the only inclusion criterion of having worked for more than six months and being working during the data collection period. Of the 43 health professionals working in the municipality, only 23 met the inclusion criterion and took part in the study.
The second group was made up of 12 older adults, aged at least 60 years old, who were waiting to be assisted at the Basic Health Unit and did not present any alteration on the previously applied Mini-Mental examination 8 .
Data collection was initiated with the health professionals, by explaining the study objectives and guaranteeing anonymity, followed by the invitation to participate in the research, delivery of a questionnaire to the participants, and the request to fill it out in the presence of the researcher.
Concerning the older adults group, the FICF was read, considering the possibility of difficulties understanding the form and, after signing it, the Mini-Mental exam and an interview were applied and the data were recorded with the aid of an mp4 player and later transcribed in full.
Once this stage was concluded, the corpus was built with the data collected, processed in LibreOffice 6.0 Writer from the LibreOffice.org package, with the file saved as a text document in .txt format that uses UTF-8 standard character encoding (Unicode Transformation Format eight bit code units) and exclusion of the questions established in the instruments, as well as of the repeated words, although the answers were kept in their entirety.
These data generated 35 texts organized in a single file, which gave rise to 35 Initial Context Units (ICUs), separated by a command line containing four variables (population, number assigned to each participant, gender, age), i.e. **** Older adult 10; 70 years old; M; **** Professional 10; Nurse; M; 28 years old).
Subsequently, the texts were processed in the IRAMUTEQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires) software, version 0.7 alpha. This software measures the analysis coming from texts and transforms them into a text corpus, which is grouped according to lexicality of the words, using the Descending Hierarchical Classification (DHC) 9 . This classification groups the text corpus into classes according to the association of words, which in turn are formed by Text Segments(TSs) according to their vocabularies, the formation of cross matrices (x 2 ) and the definition of frequency of occurrences 9 . The association of a given word with a class was determined with p-value < 0.05 or x 2 < 3.80.
The study met the ethical aspects of research involving human beings and was approved by the Research Ethics Committee of the UFPB Health Sciences Center with opinion No.: 2,190,153.

RESULTS
It is verified that, among the total of 23 health professionals included in the study, the following is observed: predominance of nurses ( Continuing the analysis of the empirical material processed from the text corpus with 35 texts, it was organized into 184 Text Segments (TS) and considered 131 TSs for the Descending Hierarchical Classification (DHC), which equals 71.2% retention. The lexicographic content was organized into five classes, which are presented in the dendrogram below ( Figure 1). Among the resulting classes, classes one and four are related to the older adults group and are called "Understanding sexuality" and "Experience of sexuality", whereas classes two, three and five are related to the health professionals and considered as "Difficulties", "Strategies" and "Defining sexuality", as described below.
Class one concentrates 17.5% of the text corpus and contains 20 TSs, mainly comprised by the vocabularies of the older adults of both genders and in the age group between 60 and 70, who attributed sexuality to talking, dating, marriage, getting pregnant and children, as the statements highlighted below: God made man and women to be married and fall in love, [...]  In relation to the experience of sexuality in class four, it represents the class with the highest percentage of text with 29 TSs (25.5%), in which the semantic content is associated with husband, sexual relation, pregnancy, condom and medication, expressed in the statements below: The difficulties experienced in the approach to sexuality by the health professionals represent 18TSs (15.8%) and mainly emphasize the taboos and preconceptions, in addition to involving a small demand for assistance to perform treatments, inform and guide, as highlighted by the health professionals: The definition of sexuality in class five, from the perspective of the health professionals and with 23 TSs (20.9%) of the text corpus, is mainly built from the nurses' and physiotherapists' statements and from understanding of the theme focused on tenderness, love, affection, pleasure, respect, desire and feeling, as highlighted below:

DISCUSSION
Despite the gender equivalence found among the participating older adults, it is noted that the female gender is predominant in the aged population of Paraíba-PB 10 , although this equivalence between genders may reflect advances in the National Policy for Comprehensive Men's Health Care 11 , by presenting responses to encourage the male gender to seek health services. In this sense, the importance of this policy is emphasized in the context of older adults' sexuality in the aging process.
It is worth noting that the higher percentage of older adults of brown race, with low schooling levels and family incomes of up to one minimum wage corresponds to the reality of most of the population living in the Northeast region. The predominance of the Catholic religion, followed by the Evangelical/Protestant ones, is justified by the fact that Brazil is a country where this religious practice is more popular (10) .
This social reality of the older adults is similar when compared to other regions of the country, as in a study conducted in northwestern Paraná, where most of the older adults had a mean of 6.4 years of studies and a mean monthly income of up to three minimum wages 12 .
In relation to their profession, most of the older adults self-declare as "Household" and a minority works in professions that demand higher schooling levels. This reality is justified considering data from the last census carried out in the country that registers the Northeast region and the state of Paraíba with a low percentage of people with university degrees when compared to other regions of the country 10 .
As for the predominance of female health professionals in the health services, it corresponds to the reality of work related to human health and social services, which evidences a higher number of females than males 10 .
The record of a higher number of professionals with latu sensu graduate studies reinforces the importance of professional qualification, as it can favor knowledge construction to plan actions in the different life cycles, such as sexuality in Gerontology.
A number of studies describe that health professionals have little training on older adults' sexuality and emphasize the absence of the theme in their training, which contributes to these professionals feeling unqualified to address older adults' sexuality during the consultations 13,15 .
From the older adults' statements in class one, "Understanding sexuality", it is observed that the interviewees associate sexuality with marriage and sexual intercourse for procreation, which is justified because most of the respondents are married, divorced or widowed, that is, sexuality in married life can be considered as a natural process obeying the individuals' physiological and emotional needs 16 .
When the older adults associated "God" and "Marriage" with the concept of sexuality, they restricted sexuality to normative conceptions such as dating, getting married and having children, which refers to religious conceptions, considering the predominance of the older adults professing the Catholic and Evangelical religions.
In addition, it is verified that sexuality beyond marriage is also associated with dating, getting pregnant and having children, which may be a reflection of a conservative education that establishes stages of socially accepted life cycles. To change this reality, conversations about sexuality must be maintained and inserted into the routine with older adults to inform them, educate them in terms of health and empower them with knowledge on the topic 17 .
The older adults' statements in class four, "Experience of sexuality", reflect that the social culture of marriage and respect for religious precepts and the prohibitive aspects of some religions directly interfere in the older adult's experience of sexuality 18 .
In addition to that, it is worrisome that the interviewees only associate condom use with pregnancy prevention, not valuing health care and the risk of contracting Sexually Transmitted Infections (STIs).
The consequences of this non-protection reinforce this concern when a total of 6,617 people over the age of 60 contaminated by HIV is recorded in the country from 2007 to June 2020 18 .
However, sexual practice without condom use by this population group shows the need to intensify educational actions about the risks of not using them and is configured as a latent discussion in this population segment, especially considering that most of the participants have low schooling levels. Such fact exerts an influence on the perception regarding the risks for diseases and engagement in healthy habits, both with themselves and with their spouses 19 .
In this sense, the weakness of the STI prevention campaigns for older adults, including health education and promotion action, contributes to the onset of these infections in this population group 20 .
The aspects described by the female older adults in the statements from class 4 should not predispose to a reduction of sexual activity, but rather to maintenance of sexuality, as older adults people to feel sexual desire and willingness 17,21,14 .
Also considering the older adults' statements from class four, the modifications linked to male sexuality stand out, which include those associated with a more flaccid erection, delayed ejaculation and problems related to the prostate, in men, generating dysfunctions and feelings of impotence and uselessness 22 .
On the other hand, male older adults are usually more sexually active because of the social discourses that associate male virility with age, as well as because of their interest in seeking effective medications that can reduce erectile dysfunction during this life phase 23 .
The statements described in class two, "Difficulties experienced in the approach to sexuality" make us reflect on the health professionals' deficits in dealing with the topic, which reinforces the importance of qualifications and of valuing the subject matter in the curricular contents during professional training.
A study with a phenomenological approach conducted in 2019 with aged individuals in San Miguel de Tucumán, Argentina, asserts that health professionals do not usually ask questions about older adults' sexuality 24 . This reality was also recorded in another study conducted in 2020 in Rio Grande do Sul, Brazil, which highlights the older adults' lack of interest and the health professionals' discomfort to ask about sexuality 14 . The authors also reveal that the professionals have little knowledge about sexuality in the aging process and difficulties with the theme; therefore, they avoid discussing it.
Even though the care logic of professionals who work in Primary Health Care is based on spontaneous demand, it can be seen that the assistance provided is based on the patients' complaints and with a curative view, and this non-assistance in this theme is also justified by forgetfulness, lack of time or low demand. This reality reinforces and points out weaknesses in older adults' care, as it disregards that they constitute the being, which interferes in understanding sexuality and in the health-disease process.
In class three, "Strategies to address older adults' sexuality", it is verified that these strategies point mainly to actions for health promotion, which is justified considering the Primary Health Care Policy in the country. In this sense, it is assumed that the professionals should adopt strategies aimed at this objective, focusing on active aging and promoting greater control in older adults over their health and sexuality.
According to a study by Rodrigues et al. 12 , the educational activities used as strategies for the care to be provided to older adults become fundamental in health promotion and in the reduction of preconceptions related to sexuality. Dialog between the health professional and the patient is essential for older adults to free themselves from sociocultural norms and may experience sexuality in old age 25 . It is also noted that most of the professionals in the study (79.8%) emphasize the need for training and to broaden their knowledge regarding the older adults' sexuality, mainly because they do not feel "comfortable" or "do not know" how to discuss the theme with this clientele.
A study conducted in 2019 in Sobral, Ceará, showed that health professionals present conservative attitudes and have difficulties carrying out activities focused on older adults' sexuality, despite having due knowledge 7 . Thus, positive attitudes and feelings of selfefficacy in older adults need to be encouraged by the health teams, which are concerned with designing comprehensive gerontological assistance and with incorporating health education activities that address the different specificities of older adults, especially sexuality, which permeates all life cycles 26 . In this aspect, consultations with health professionals represent a strategic space to portray sexuality with older adults.
A study conducted in Picos, Piauí, which aimed at evaluating the health education actions on sexuality among older adults, evidenced that the knowledge level of this population on this theme was considered low, requiring a change at the governmental level and in society, as well as the health professionals' actions in health promotion considering the "aging and sexuality" perspective 26 .
Finally, the description of the reports indicates that involvement of the multiprofessional team represents a fundamental strategy to intensify proper assistance regarding sexuality in the aging process. Considering the Primary Health Care context, the performance of fixed teams and the Extended Family Health Center (Núcleo Ampliado de Saúde da Família, NASF-AB) reveals the multiplicity of knowledge and behaviors that can be drawn in the approach with older adults, as it is a complex theme and requires overcoming challenges to provide comprehensive and holistic care to this clientele 27 .
Regarding the statements in class five, "Defining sexuality", it is verified that the professionals present an expanded and subjective concept about sexuality, which is expressed in the several ways of experiencing pleasure, that is, tenderness, affection, respect, desire and love for the other, considered as ways of experiencing sexuality in older adults 6,28 .
It is also noted that the concept of sexuality reported by these professionals relates feelings and affection, diverging from the one described in class one, Understanding sexuality by the older adults, who relate sexuality to marriage and procreation.
Such being the case, sexuality can be expressed and experienced in different ways, under the influence of social, psychological, religious, historical, spiritual and biological factors 2,9 . Given the above, it is noted that sexuality is inseparable from human personality and integrates the other human needs, especially in terms of intimacy and social relations 20 .
In this sense, affective elements such as love, tenderness and respect are responsible for a set of diverse feelings and different behaviors which, although varied, are related to each other and are inherent to human beings throughout their lives 3,6 .
Reinforcing the above, a study about sexuality conducted in Belém, Pará, describes that it is understood in bodily language, from affective experiences and feelings demonstrated by individuals, and that lack of knowledge about sexuality from youth influences quality of life and, consequently, the aging process 1,2 .
Consequently, it is assumed that health professionals have certain knowledge about sexuality, although they seldom use it in the practice. To change this reality, it is considered that expanding the bond between health professionals and the service users becomes a possible strategic tool to approach older adults about this theme.
It is understood that the current study represents a knowledge source; however, it is not free from limitations, the main one being related to the sample size, as well as to the reduced number of references from the last five years. It is believed that the research will serve as an incentive for health professionals to expand their knowledge about older adults' sexuality.
The study allowed understanding the experience of the aged individuals and health professionals regarding older adults' sexuality and, through the older adults' statements, it was also possible to notice the need to expand the concept of sexuality, as well as for guidance on the topic and the various aspects that interfere with their sexuality.
The need to train health professionals to broaden their knowledge is also emphasized, so that the theme can be discussed and worked on in health services, minimizing prejudices and taboos to improve older adults' quality of life.
Thus, the study contributed to expanding knowledge about older adults' sexuality, based on the need for health professionals to maintain a harmonious and empathetic relationship, creating bonds with aged people. Therefore, it becomes fundamental that, during the consultations, the professionals may clarify doubts and be open to qualified listening, having a trustful relationship with the older adults, so that, through dialogue, they can guarantee special attention, allowing them to fully experience their sexuality with self-knowledge, autonomy and independence.