Introduction

It is estimated that mental disorders account for 12% of diseases¹. Among them, common mental disorders (CMD), one of the most prevalent psychic morbidities, affect about one third of the population in different age groups stand out¹. CMD are sentimental manifestations of uselessness, insomnia, difficulty concentrating, irritability, fatigue, forgetfulness and somatic complaints that are allied to anxiety and depression².

CMDs are responsible for the high social and economic impact, due to absences at work and increased demand for health services³, in addition to undesirable impacts on personal and family well-being, thus constituting an important public health problem. In the context of the elderly, situations of low productivity, abandonment and social isolation, among other factors, can increase exposure to psychic comorbidities and negatively affect health¹.

It is worth mentioning that Brazil will be the sixth country with the highest number of elderly people worldwide by 2025⁴, which highlights the imprescindibility of actions that add quality to the additional years of life of the elderly, thus fulfilling the proposal for health promotion and protection and active aging. In this sense, sexuality can be a relevant field to be explored, especially by nurses of the Family Health Strategy (FHS), a care model of primary health care in Brazil. We mention the FHS because it is the main model of reordering of the health network in Brazil, and in other countries, primary care can be performed by different models that can also constitute a field for the development of sexuality practices with the old people.

Sexuality integrates a set of basic needs of the human being and must be fully and satisfactorily experienced⁵. It is defined as a multidimensional component in which the individual explains thoughts, feelings and cognitions, such as expressions of love, affection, intimacy, companionship, touch, embrace, including sexual activity⁶. Therefore, it is a natural process that responds to a physiological and emotional need of the human being, manifesting itself in separate ways in the separate phases of the life cycle⁴.

Thus, sexuality is present at all ages, does not disappear in old age⁵ and only has an end after the death of the individual⁶. It is worth mentioning that the aging process does not preclude the experiences of sexuality by the elderly⁷. On the contrary, the satisfactory experience of sexuality in old age contributes significantly to the quality of life^4,6, health and well-being of the old person⁶.

It should be remembered that aging occurs in a singular and complex process but does not mean dependence or functional disability. It is emphasized that, even if there are functional losses, old age can be experienced successfully⁴. However, the great problem is that most professionals in the FHS do not consider sexuality in their care practices, due to the predominance of health care focused, always, on pathological and curative aspects⁸.

In addition, sexuality in old age is surrounded by various myths and prejudices by today's society. The false belief that sexuality is allowed only in youth contributes to the social strengthening that their experience in old age is an unusual and immoral practice. Nevertheless, this social construction also has impacts on health care, as it culminates in the lack of attention of professionals about the need to address this theme in their consultations, and, therefore, contributes to increasing the vulnerability of the elderly⁷.

In this context, considering the importance of sexuality in the health of the elderly; the lack of approaches by health professionals and, especially, the need to invest in new care strategies focused on health promotion and protection, the development of this study is justified to deepen discussions about integrality of care and the benefits of sexuality in the health of the elderly. Thus, the hypothesis of this study is that sexuality is associated with biosociodemographic variables and correlated with the suspicion of CMD in this population. To evaluate it, the objective was through this study to analyze the association between sexuality experiences with biosociodemographic variables and mental health of the elderly.

Materials and methods

This is a cross-sectional, descriptive and analytical study constructed according to the recommendations of the STROBE checklist⁹.

To determine the sample, an infinite population, prevalence of CMD in the elderly of 25%1, α=0.05% and CI=95%, resulting in a minimum sample of 289 elderly participants living in the community. However, more participants were added to compensate for possible losses and rates of non-responses, totaling a final sample of 300 elderly people who met the following inclusion criteria: being 60 years of age or older, according to Brazil’s standardization, being married or having a fixed partnership, due to the instrument used also considering the sexuality experienced between the spouse, being, therefore, a mandatory item10; of both sexes (male and female) and reside in northeastern Brazil. Elderly residents in long-stay and similar institutions and those hospitalized during the data collection period were excluded. Because they are elderly with active interaction in social networks and skills in the handling of electronic devices that allow internet access, the application of an instrument for cognition assessment was dispensed with.

The data were collected exclusively online between August and October 2020 through the Social Network Facebook. A page was created for the development of scientific research, where researchers published the hyperlink for access to the research questionnaire. This hyperlink was accompanied by an invitation in the form of a digital banner that invited the target audience to participate in the study. Nevertheless, the authors used the geolocation strategy, in which it was possible to delimit only the northeast region as a study scenario, in addition to applying monthly the post boost, so that Facebook could expand the dissemination to as many people as possible, until the sample size reaches.

The survey questionnaire was prepared by Google Forms and organized into three blocks: biosociodemographic, sexuality and mental health. It is noteworthy that, before the participants had access to the questionnaire, it was required to include the e-mail in the requested field, so that the researchers could reduce biases by identifying multiple answers by the same participant. In addition, in a page prior to the instruments, the Free and Informed Consent Form (TCLE) was made available, and to continue the study, the participant had to click on the option "I read and agree to participate in this study", a mandatory step.

The biosociodemographic block was delineated with questions constructed by the researchers themselves to trace the profile of the participants, such as age group, sexual orientation, religion, sex (male and female), ethnicity, marital status, time living with the partner, whether living with the children, sexual orientation and whether they have had guidance on sexuality by health professionals.

The sexuality block was elaborated with the Scale of Affective and Sexual Experiences of the Elderly (EVASI) built and validated in Brazil¹⁰. It is a scale structured in three dimensions: sexual act, affective relationships and physical and social adversities, besides having 38 items with five possibilities of answers: (1=never), (2=rarely), (3=sometimes), (4=frequently) and (5=always). The scale has no cut-off point and the result is interpreted in the perspective that the highest/lowest score represents, respectively, the best/worst experience of sexuality by the elderly¹⁰. During the validation process, the author found good reliability for the three dimensions through Cronbach's alpha: sexual act (α=0.96), affective relationships (α=0.96) and physical and social adversities (α=0.71)¹⁰.

Finally, the mental health block was elaborated with the Self-report Questionnaire (SRQ-20), validated for Brazil^11,12with the objective of tracking the suspicion of CMD. It consists of 20 questions that assess four domains: depressive-anxious mood, somatic symptoms, decreased vital energy and depressive thoughts. All possibilities of answers are dichotomous (yes/no), which allows the achievement of a minimum score of 0 points (no probability) to a maximum score of 20 points (extreme probability) of the participant having CMD. A cutoff point was ≥ positive responses for both sexes, according to previous studies¹³. The SRQ-20 instrument presents sensitivity of 83% and specificity of 80%¹¹, besides presenting satisfactory reliability through Cronbach's alpha of 0.86¹².

The data were stored and analyzed by the statistical software IBM SPSS®. After verifying the abnormal distribution of the data using the Kolmogorov - Smirnov test (p<0.05), descriptive and nonparametric analytical statistics were used, the results of which are expressed in percentage, median, interquartile interval, average rank and test statistics. The Mann-Whitney test was used to analyze the variables with two categories and the Kruskal-Wallis test to analyze the variables with more than two categories. For the analysis of the independent variable (sexuality) and the dependent variable (mental health), spearman's correlation (ρ) was used, adopting a 95% confidence interval (p<0.05) for all statistical analyses.

This study was approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing of the University of São Paulo in 2020, under Opinion N 4,319,644 and Certificate of Presentation for Ethical Appreciation (CAAE): 32004820.0.0000.5393.

Results

The present study predominated the elderly male (n=206; 68.7%), aged between 60 and 64 years (n=128; 42.7%), self-declared white (n=213; 71.0%), with higher education (n=137; 45.7%) and who never received guidance on sexuality by health professionals (n=227; 75.7%). Moreover, there was a general prevalence of CMD of 31% (n=93) and the elderly males were the most affected, according to Table 1.

According to Table 2, the Mann-Whitney test showed a significant association between females and somatic symptoms and decreased vital energy. The Kruskal-Wallis test showed that the elderly aged between 65 and 69 years better experience the sexual act. In addition, those with a fixed partnership better experience the sexual act, better experience affective relationships and have lower physical and social adversities related to their experiences in sexuality (Table 2).

Table 3 shows that the elderly with suspicion of CMD had the lowest median snags in the dimensions of sexual act and affective relationships, indicating that this worse group experiences these two dimensions of their sexuality when compared to the elderly without suspicion. Nevertheless, it was observed that participants with suspicion of CMD had a higher median in the physical and social adversities dimension, evidencing that they have worse coping with such adversities (Table 3)

Table 4 shows that all dimensions of sexuality are significantly correlated to all SRQ-20 domains. However, the correlations were weak and moderate, and the highest correlation identified was negative between affective relationships and feelings related to depressive-anxious modo (Table 4).

Discussion

This study showed a general prevalence of 31% of CMD among Brazilian elderly. In addition, male participants were the most affected by psychic morbidity, which differs from a similar study in which they identified the most prevalent female gender¹. It is worth noting that estimates of the prevalence of CMD have considerable variations in the literature. However, one in six people living in community may present with these disorders and 50% of affected people present symptoms that require interventions by health professionals¹⁴.

The significant association between females found in this study was with somatic symptoms and with decreased vital energy. Somatic symptoms are characterized by headache, poor digestion, insomnia, inappetence, stomach discomfort, and hand tremors. The decrease in vital energy involves fatigue, suffering in work activities, difficulty in decision-making, feeling satisfaction in tasks and thinking clearly¹⁵.

Suffering among women is linked, but not restricted, to social construction and gender issues. In this sense, it should be highlighted that throughout the socialization process, women were conditioned to be contained in their emotions, which may favor emotional discharges manifested by psychic suffering and CMD¹⁶. In this sense, it should be considered that women who are old today have gone through childhood, youth and adulthood, besides having experienced the reproductive and non-reproductive phase and several other social and personal contexts. Thus, the way these women experienced all these specificities quantitatively can have repercussions on the way they perceive and experience their sexuality in old age.

*Statistical significance by the Mann-Whitney (p<0.05).

†Statistical significance by the Kruskal-Wallis (p<0.05).

In this context, a study conducted with adult women revealed that older participants with low schooling, with few hours of sleep, separated or widows integrate the follow-up with greater vulnerability to CMD and, therefore, should be considered with priority in health services¹⁷. Thus, the high prevalence of CMD among females exposes a more challenging aging process, since these women have already been subjected to overloads in most of their lives, had restricted access to leisure, live with chronic diseases and dysfunctions, and several other adversities arising from gender roles¹⁶.

Another relevant finding of our study concerns the predominance of elderly who have never received guidance on sexuality by health professionals. Any orientations conducted by these professionals are considered educational practices that are part of the field of health education and permeate several themes related to the needs of users¹⁸.

It is noteworthy that educational actions have as main objective to make those involved active about their health, respecting their autonomy and valuing their potential, so that the change of behavior is effective and promotes benefits in quality of life¹⁹. In this context, the FHS is consolidated as a locus of educational actions, since the integrality of the work developed by professionals enables and provokes efforts capable of cooperating in the maintenance of individual and collective health, which in turn mobilizes critical and transformative thinking of personal and social changes²⁰.

In this perspective, a study¹⁹ conducted with 1,281 elderly showed that the guidance provided by health professionals can positively contribute to the adoption of healthy practices and reduction of habits harmful to health, constituting a powerful strategy for the promotion of the health of the elderly¹⁹. Thus, the professionals of the FHS have extremely relevant functions in the development of educational actions planned and directed with a view to the quality of life of users. Such actions should be articulated in a multiprofessional way and have a permanent character for the achievement of health promotion²⁰.

The fact is that sexuality in old age remains a field neglected by health services and the public authorities, being considered as something nonexistent in old age²¹, which contributes to more conservative attitudes among professionals^7,21and the difficulty of the elderly requesting information on the theme²².

Thus, it is necessary to promote comfort in the environment so that the elderly have freedom to express their emotions and needs without fear or shame²², because the full and satisfactory experience of sexuality in old age contributes significantly to the promotion of better health, well-being and quality of life^4,6and its suppression or annulment promotes undesirable events to the health of the elderly, in addition to accelerating the aging process^21,23.

Another relevant finding of the present study is that the elderly aged between 65 and 69 better experience the sexual act, demystifying the erroneously publicized belief that the elderly are asexual beings and who do not have desires6. However, it is known that the elderly continue with desires and sexual activities are influenced by several factors such as gender, availability of partners, health, interest of those involved, among others^24,25.

Corroborating these results, a study²⁶ conducted with Polish elderly showed that, despite the stereotype of asexuality, the elderly were sexually active, and that sexual satisfaction was statistically associated with overall satisfaction with life. These findings reinforce the need for and importance of healthy living of sexuality among the elderly^26.

Also in this sense, another nationwide study²⁷ conducted with English elderly observed that, among the group aged 80 years or older, 19% of men and 32% of women had sexual activities frequently, at least two or more times a month. In addition, the authors point out that, although the frequency of sexual relations decreases over the years, the older people, including octogenarians, continue with active sexual life²⁷.

It is noteworthy that sexual activity in old age is important because it also involves expressions of affection, admiration, loyalty and mutual trust. In the elderly, sexual practice contributes to maintaining high energy levels with positive repercussions on self-confidence, which in turn reaffirms their physical capacity and helps in the face of the aging process²⁶. Nevertheless, sexual activity and intimacy are statistically associated with positive results in interpersonal relationships, quality of life, physical and mental health^24,28, in addition to reducing the physical problems resulting from aging⁶, which once again demonstrates the need to consider it during care practices.

Another interesting fact is that the elderly with a fixed partnership better experience the sexual act, better experience affective relationships and have lower physical and social adversities. Physical and social adversities are represented by the perception of the elderly in relation to health and its influence on sexual experiences; in the personal discomfort resulting from the changes caused by aging and the fear of being victims of prejudice because they take attitudes that favor their experiences in sexuality²⁰.

These results draw attention because most of the participants were married and it was hoped that marriage would be a factor that would allow deep experiences in sexual and affective relations, in addition to better coping with physical and social adversities.

This is because marriage, especially in Brazilian culture, is considered as a space of affection and the affective and sexual needs between the spouses strengthen and maintain healthy the marital dynamics²⁹. However, the social roles played by the elderly within marriage condition them to a state of comodism. This inference is supported due to routine and monotony in the relationship between married spouses over the years that can negatively influence the way elderly couples conceive the expression of their sexuality³⁰.

Moreover, in the present study, the elderly with a fixed partner are widowed or divorced individuals who have overcome prejudices related to sexuality in old age and have allowed themselves to experience new opportunities in relationships, with a view to obtaining pleasure and filling in your identity while being sexual whose sexuality manifests itself in different forms and moments of life. This reality may justify, in part, the reason for the elderly with a fixed partner to experience their sexuality more deeply when compared to the elderly married or in stable union.

It was also found that the elderly with worse suspicion of CMD experience the sexual act and affective relationships, when compared with the elderly without suspicion. In addition, it was observed that participants with suspicion of CMD had a higher median in the physical and social adversities dimension, evidencing that they have worse coping with such adversities. These results reveal that the suspicion of CMD is associated with a worse experience in sexuality by the elderly, which points to a situation of alertness, because the presence of CMD that already promotes undesirable events in the person's life interferes in other aspects that could function as a protective factor, such as sexuality.

In addition, the best experiences in affective relationships are statistically correlated with lower feelings related to depressive-anxious mood, although the strength of the correlation found is moderate. The depressive-anxious mood dimension is composed of symptoms of worry, fright with ease, nervousness, tension, crying and sadness²⁵. In the same sense, a study1 conducted with 310 Elderly Brazilians identified that the dimension of depressive mood (nervousness, tension, worry or ease of scaring) were the most prevalent among the participants.

The fact is that sexuality remains an integral component of quality of life²⁴, identity, social relationship and mental health of many elderly⁶ and, therefore, its consideration is fundamental for the planning of health actions and services. Thus, the broad understanding of sexuality in old age favors the improvement of education, research, politics and care to this population group with significant growth worldwide²⁴.

It is noteworthy that this study has some limitations that should be considered. First, due to the non-probabilistic methodology, the results revealed here may not represent the population and compromise the external validity. Another limitation concerns the various cut-off points of the SRQ-20 adopted in the investigations with the elderly, which compromised the comparison of our results with other national and international studies. Finally, it is noteworthy that most participants declared themselves white and with an elevated level of education, which reflects in a socioeconomically privileged minority, which in turn may not represent the reality of the Elderly Brazilians, especially users of the Public Health System, although access is universal and egalitarian.

It is worth mentioning that these limitations do not cancel out the relevance of the present study for the knowledge and dissemination of information on the benefits of sexuality in the mental health of Brazilian elderly. However, it is suggested that more investigations be developed with the elderly with greater vulnerability, to subsidize actions in sexuality that are closer to the reality of users.

Conclusion

This study showed a statistical association between the sexual act and the age group of the elderly. In addition, all dimensions of sexuality were associated with marital status and were significantly correlated with all domains of mental health. However, the correlations were weak and moderate, and the highest correlation identified was negative between affective relationships and feelings related to depressive-anxious mood. It is noteworthy that these results point to the need to consider the sexuality of the elderly as a factor that adds better mental health.

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest.