|Year : 2016 | Volume
| Issue : 2 | Page : 91-99
Psychobiology of love and sexual relationships in elderly: Issues in management
TS Sathyanarayana Rao
President, Indian Association for Geriatric Mental Health, Editor, Indian Journal of Psychiatry, Secretary, Human Sexuality Section, World Psychiatric Association, Department of Psychiatry, JSS Medical College, JSS University, Mysore, Karnataka, India
|Date of Web Publication||13-Dec-2016|
T S Sathyanarayana Rao
Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sathyanarayana Rao T S. Psychobiology of love and sexual relationships in elderly: Issues in management. J Geriatr Ment Health 2016;3:91-9
|How to cite this URL:|
Sathyanarayana Rao T S. Psychobiology of love and sexual relationships in elderly: Issues in management. J Geriatr Ment Health [serial online] 2016 [cited 2017 Jun 29];3:91-9. Available from: http://www.jgmh.org/text.asp?2016/3/2/91/195598
"There is no subject in our society that is associated with more myths and misinformation than that of sexual intimacy and the elderly. The myths surrounding sexual intimacy in later years are finally being put in their proper place-behind us"
-From the book, "Intimacy Matters: Elderly Sexuality, Edited by T.S.S. Rao, S. Gupta, Abhinav Tandon - 2011.
"People are just people, and if you had basic human needs when you were 20, you are going to experience the same basic human needs when you are 70"
Esteemed Seniors, Colleagues, and Friends,
I am both humbled and privileged at the same time, being given the responsibility to lead this esteemed organization, ably served all these years by worthy luminaries. I am confident, with your continued support and guidance; this specialty association should grow immensely in the coming days and leave a mark in our society. Aging is bound to catch up with everybody, but unfortunately, many are not well prepared for the same. We cannot be mute spectators and land in crisis without being prepared properly. The burgeoning-aged population is already amid us; in fact, some of us are already a part of this group and it is imperative to attend to all the aspects of one's life. The "Quality of Life" (QOL) is a paramount concept encompassing myriad of issues. However, I will concentrate on issues of intimacy, relationship, love, and sex as they influence the QOL of the individual, in general and sexuality, in particular.
| Intimacy, Sensuality, and Sexuality|| |
Human sexuality refers to the ways in which we experience and express ourselves as sexual beings. It is the constitution of an individual in relation to sexual attitudes or activity. Broadly, it includes aspects of the physical, psychological, social, and spiritual makeup of an individual and encompasses the manner in which individuals use their own roles, relationships, customs, and gender.  Our awareness of ourselves as females or males is a part of our sexuality as is the capacity we have for erotic experiences and responses. It is a complex topic, and no single theory or perspective can capture all its nuances.  Although many people in our culture see sexual activity as appropriate only for the young,  age evolves one sexually which makes lovemaking far more intimate and sensual: Sensual implies to devotion toward gratification of the bodily pleasures and luxuriousness. Contrasexual transition (by Carl Jung) refers to men and women crossing sexual and psychological paths at midlife,  which makes women more assertive and men more nurturing and intimate. The Turkish proverb "Young love is from the earth, and late love is from heaven" is most appropriate here. 
Love is the absolute dedication of the entire being to the beloved, without fear or vulnerability, pain, or the madness of its intensity with trust to take responsibility for the soul and body.  Love is a divine energy that creates life to accept it with joy, acknowledge its sacredness, and embrace it with a positive mind.  Sternberg , has theorized that in a relationship, the passion component of love peaks early whereas the other two components, intimacy and commitment, continue to build gradually over time. The word intimacy (Latin - intima) means inner or innermost. Webster's Dictionary defines intimate as "belonging to or characterizing one's deepest nature, suggesting informal warmth or privacy, of a very personal or private nature." Intimacy requires an ability to be both separate and together as participants in a relationship. Intimacy does not necessarily mean sex. However, very often, an individual with whom we have a soul-to-soul connection is the same with whom we have a sexual agreement. Many people who are not able to get intimate with their partners complaint of sexual problems. Sharing life with someone with whom we can be free to be ourselves, a person who can protect oneself from the stresses of modern life, all proponents to intimacy to feel loved and wanted is a basic human necessity. Talking, as well as listening, and nonverbal communication form the core of an intimate relationship. Experiencing physical touch, as in kissing, erotic touch other than during sexual activity,  a careless whisper that pulls the face closer increase intimacy in a relationship. Commitment to a relationship would include sexual fidelity, spending time with each other, and agreeing for a lifetime of togetherness.  With the introduction of sexual intimacy in a relationship, it becomes more complex; sexual activity involves merging emotional, spiritual, and physical intimacies. A sexual experience may include an erotic foreplay, a massage, mutual masturbation, or an intercourse with an intimate partner which gives an ecstatic union.  A couple who is creative and avoids monotony is likely to experience sensual pleasures. Performance anxiety can be easily overcome in an intimate relationship. With increasing life expectancy and advancement in our understanding of sexual medicine, those in their sixties and beyond can expect a sexually active and intimate relationship with their partners.
| Neuropsychobiology|| |
The "Sexual Response Cycle" includes different phases such as desire, excitement, orgasm, and resolution phases (Sexual response cycle as described by Masters and Johnson in 1970 included the excitement, plateau, orgasm, and resolution phases) ,, The sexual response cycle is mediated by a complex interaction of the somatic and autonomic nervous systems which operate at cerebral, spinal, and peripheral levels. Cortex controls and processes sexual stimuli. Positron emission tomography has revealed that orbitofrontal cortex processes emotions, left anterior cingulate cortex is related to hormonal control and sexual arousal, and right caudate nucleus activity decides whether sexual activity will follow. Various parts of the limbic system stimulate penile erection; hippocampus influences genital tumescence and release of gonadotropins; amygdala is believed to regulate oral and genital behavior. The third subdivision of the limbic system is associated with visual stimuli in context of sociosexual behavior. Brainstem has excitatory and inhibitory control over spinal sexual reflexes. The nucleus paragigantocellularis has inhibitory control over climax such as responses in men through lumbosacral spinal cord efferent neurons, stimulating them to secrete serotonin which inhibits orgasm. Penile tumescence occurs through synergistic activity of sympathetic and parasympathetic autonomic nervous systems. The sympathetic system mediates psychologically induced impulses. The nervous system is modulated by various hormones which affect male and female response differently. Testosterone is the hormone connected with libido in both men and women. Stress is inversely related to blood testosterone concentration. Other factors such as mood, lifestyle, and sleep influence blood testosterone concentration. Testosterone is released in a pulsatile manner, in a diurnal rhythm (peak levels in the morning and lowest levels in the evening), under the influence of hypothalamic-pituitary-gonadal axis. Decrease in testosterone concentrations (normal 270-1100 ng/dl) is noted from the age of 50 years, at the rate of 100 ng/dl per decade, and sensitivity of androgen receptors decreases in men with age; however, healthy aging men never become hypogonadal. Testosterone levels in saliva of heterosexual adolescent men correlate positively with the number of times they initiated sexual contact (although whether sexual contact led to the increase in androgens needs to be confirmed).  In both men and women, orgasm (induced by masturbation) increases sympathetic activation leading to an increase in heart rate, blood pressure, and plasma noradrenaline levels (transiently) and an increase in plasma prolactin level for 30 min in men and 60 min in women. , In women, sexual arousal increases plasma luteinizing hormone and testosterone levels.  The neurohormone oxytocin is also released during orgasm and reinforces pleasure.
Neurotransmitters such as dopamine, serotonin, epinephrine, norepinephrine, and others influence sexual functioning. At the central level, dopaminergic and serotonergic systems play an important role in various phases of the sexual response cycle although adrenergic, gamma-aminobutyric acidergic, and other neuropeptide transmitter systems may contribute as well. At the peripheral level, the vascular changes (leading to vaginal lubrication and penile erection) are mediated by adrenergic and cholinergic systems and nitric oxide release. Aging, disease, surgery, or medications may disrupt the endocrine, neuronal, or vascular response leading to sexual inadequacy. Psychological and relationship factors play an equally important role in healthy sexual functioning.  The physiological changes with aging include a longer time to attain erection, decreased penile turgidity, and ejaculatory seepage. In women, decreased vaginal lubrication and atrophy are associated with lower estrogen levels. 
| Psychosocial issues and sexual functioning in elderly|| |
Psychosocial factors can have a strong impact on sexual functioning of an individual. Attitude toward sex and masturbation, impact of religious and cultural beliefs, and lack of privacy have an influence on sex lives of elderly. Belief of caregivers that sexual activity is meant only for the young and elderly are asexual beings. Sexuality is a lifelong process; however, some elderly people, their children, and health care providers hold a contrary view despite studies reporting that older people can be potentially sexually active into later life. , Emotional strain between the elderly and their children/care givers, intra-psychic conflicts, and relationship problems either due to lack of intimacy, giving inadequate time to the spouse or poor communication, lack of trust, mismatches in sexual desire, boredom, and poor sexual technique can all have a negative impact. In elderly, a feeling of entrapment into the relationship, with an inability to break off from the commitment, may lead to anger and resentment. Psychosocial stresses, such as death of a spouse, loss of social status, poor support networks, health- and finance-related problems, may contribute to sexual difficulties in older people by increasing the likelihood of depression or anxiety. , Education regarding sexual health in elderly, clarification of myths, and misconceptions regarding sex can considerably enhance sexual functioning in the elderly.
| Research and elderly sexuality|| |
There is relatively a very small volume of research in geriatric sexuality and is practically nonexistent in the developing world. Most research articles have emphasized the importance and relevance of sexual functioning in the lives of the elderly. , Popular stereotypes of old individuals as nonsexual have been criticized with implications for research and policy. 
The incidence of sexual dysfunction increases in old age; however, this is related to increased rate of health problems, rather than old age per se.  Deacon et al.  have concluded that cardiovascular disease, diabetes mellitus, dementia, arthritis, drugs, and surgery have a major negative influence on sexual functioning in the elderly. Medications such as antihypertensives and antidepressants can adversely affect erectile function and libido.  Erectile function is the most important factor in a healthy sexual life in elderly. Chronic, uncontrolled hypertension and diabetes may lead to erectile dysfunction (ED). Obesity, smoking, hypercholesterolemia, heart disease, and lack of physical activity are other risk factors for ED.
In women, lack of a physically capable partner is a frequent problem (as women outlive men) and women report significantly less sexual activity than men at all age groups.  Many medical conditions such as osteoarthritis and changes in body mass and shape contribute to a reduced desire for sex in women. 
The prevalence of ED increases with age; it is 1-9%: <40 years, 2-9% and 20-30%: In 40-59 years age group, 20-40%: In 60-69 years age group, and 50-75% in the seventh and eighth decades. Prevalence rates for ejaculatory dysfunction range from 9% to 31%.  A study done by TSS Rao, Darshan MS, and Abhinav Tandon in Suttur village in South India found that among those above 60 years of age and sexually active, 43.5% of the male subjects had ED, 10.9% premature ejaculation, 0.77% male hypoactive sexual desire disorder, and 0.38% male anorgasmia. Among females, the prevalence of female arousal dysfunction was found to be 28%, female hypoactive sexual desire disorder 16%, female anorgasmia 20%, and dyspareunia 8% of the female subjects.  This study has concluded that sexual problems are very much common among both men and women in the older population. Among males, ED was the most common whereas in females, arousal disorder was the most common female dysfunction noted, implicating that biology plays an important role in men, whereas psychology plays an important role in women sexual functioning.
| Management of sexual inadequacies|| |
As in all psychiatric interviews, one needs to develop rapport in an accepting atmosphere with a nonjudgmental attitude. Sexual history needs to be more structured though areas of concern for the patient should be explored positively. Both recent and early sexual history needs to be noted. The current sexual complaints, life stresses, sexual practices, contraceptive use, partners, relationship problems, sexual fantasies, masturbatory history, extramarital affairs, and commitment to partner should be enquired into. If married courtship period, honeymoon and reproductive history should be looked into. Mutual physical attraction, temporary separation, and the effect of children on couple's sexual life should be noted. Changes in sexual functioning and frequency and quality of sexual interactions with age should be detailed. The partner's contribution to the present distress, lifestyle factors, and psychiatric history including history of substance abuse should be ascertained. The patient's self-image as a sexual being through childhood and adolescence and people who contributed to patient's sexual education and identity needs to be detailed. Any history of group sex, homosexual encounters, and abortions should be considered and enquired. Sexual orientation of the patient, any high-risk sexual behavior, and sexual abuse history should be kept in mind. Regardless of sexual orientation, each phase of the sexual response cycle applies equally to both heterosexual and homosexual partners and methods and principles of treatment are similar. 
Careful history taking should be followed by a physical examination in all the cases after obtaining consent and maintaining privacy to rule out organic disease and make a note of any contributing general medical illness. Laboratory studies should include a urine analysis, blood tests for complete blood count, kidney and liver function tests, lipid profile, fasting blood sugar, thyroid function, other endocrinal tests, and laboratory tests related to general medical illness if any. Nocturnal penile tumescence, intracavernous pharmacologic injection using a vasodilating agent such as papaverine, duplex color ultrasonography, dynamic infusion pharmacocavernosometry, and caver nosography, and pharmacologic pelvic penile angiography are the other tests in some selected cases. It is necessary to understand relationship difficulties among the couple, whether partner is sympathetic or not sympathetic toward the problem, their expectation and motivation for treatment. Differentiating features between organic and psychogenic sexual dysfunction need to be established well before the active management.
| Psychotherapeutic intervention|| |
Sex therapy as it is referred to today is essentially a modified form of the original therapy (as founded by Masters and Johnson in 1970) and follows a brief, problem focused, and behavioral approach. Based on classic psychodynamic theories, resolution of early developmental conflicts, acceptance of sexual impulses to the ego, and resolution of the problem was the main focus. The "new" sex therapy focuses on relief of immediate symptoms and acts as a bridge between the psychoanalytic and behavioral approaches. Psychodynamic approaches are only used if the initial behavioral techniques do not produce symptom relief.
As elaborated by Masters and Johnson in 1970, sex therapy (dual-sex therapy) ideally includes involvement of both the partners. Anatomy and physiology of sexual function are explained in brief and doubts cleared by a male-female pair of cotherapists. Therapy emphasizes that there is no use blaming one's partner or oneself, and sex is a mutual act between two individuals. Interpersonal communication at a highly intimate level and enhanced social communication benefit the relationship.  Education, heightening sensory awareness, and sensate focus exercises are taught to the couple. Behavioral exercises include sensate focus (nondemand pleasuring) to allow the individual to re-experience pleasure without any pressure of performance or self-monitoring. The assessment and treatment need to be tailored depending upon one's setting, profession, specialty, and most important of all, the type of the problem encountered in the client, wherein different approaches may be helpful.
| Behavioral techniques|| |
Sexual dysfunction is considered as a maladaptive behavior by behavioral therapists. Using a hierarchy of anxiety-provoking sexual interactions, the client systematically desensitized.
Different approaches include Masters and Johnson's approach, Kaplan's approach, and the PLISSIT MODEL with some variations in the treatment process. Annon (1974) proposed a graded intervention popularly called as PLISSIT MODEL wherein the individual letters stand for P: Permission giving; LI: Limited information; SS: Specific suggestion; and IT: Intensive sex therapy.
In the permission giving phase, the client is assured that their thoughts, feelings, fantasies, and behaviors are normal until they are not affecting the partner in a negative manner. In "limited Information" phase, the client is given information related to his or her sexual problem. In "Specific Suggestion," behavioral exercises such as start-stop technique, "sensate focus" are taught and homework assignments are given. These help in improved communication between the couple and in learning new arousal behaviors. Intensive therapy is considered if the first three fail. Here, insight oriented and psychosexual approaches are taken to make the client aware of their feelings. ,,,
Sex therapy involves primarily sensitization, desensitization techniques.  The general principles are applicable to majority of the inadequacies encountered in clinical practice. The major guidelines to be followed are (i) educating the couple, (ii) setting the framework for the therapy, (iii) proscribe sex, (iv) sensate focus exercises, (v) systematic sensitization, and desensitization: The couple is advised to talk on issues bothering them in a nonjudgmental way, encourage partners to see, hear, and understand each other's perception, and teach verbal and nonverbal communication skills,  in general and during sexual activity in particular.
| Other therapies|| |
In couple and family therapy, (also known as marital therapy and family counseling) the therapist works with families and couples in intimate relationships, regardless of whether the client considers it to be an individual or family issue. In eclectic approach, the therapist uses a theoretical concept which leads to improvement of a couple's relationship. Ideally, in marital therapy, both partners are counseled together. It is important to first ascertain whether love and concern exist for each other. Communication pattern between the couple and the power structure of their relationship needs to ascertain. The therapist could by exaggeration highlight the method of relating to each other in a couple and their communicative pattern. The therapist by modeling demonstrates methods such as genuine listening, encouraging, and empathizing by which love and tenderness can be can be expressed. ,
Emotions focused couples therapy
This is a short-term intervention to reduce distress in adult love relationships and create more secure attachment bonds. 
Behavioral marital therapy is a skill-oriented approach emphasizing that couples need basic skills and understanding of relationship interactions to improve their marriages. The focus is the current marital relationship and improving positive communication. 
Cognitive-behavioral couple therapy grew as an extension of behavioral couple therapy. It is based on the concept that relationship distress includes cognitive, behavioral, and affective components that influence each other. 
| Pharmacotherapy for sexual dysfunction|| |
Nitric oxide enhancers
These drugs improve inflow of blood into the penis and improve erection. The first drug developed in this class was sildenafil citrate. It acts on the nitric oxide mechanism by blocking phosphodiesterase-5 enzyme. It is the first approved nonsurgical treatment for ED and was approved by the US Food and Drug Administration in 1998 for prescription sale. It is rapidly absorbed after oral administration and has to be taken 1 h before sexual activity which is the time required for peak plasma concentrations to be reached and the effect may last for up to 4 h. The starting dose should be used on at least four occasions to precisely access the efficacy and tolerability. If a satisfactory sexual performance is not achieved, the dose should be increased to the next higher level. Studies have clearly demonstrated that there is a dose-response curve with sildenafil and the best results are obtained up to a maximum dose of 100 mg. ,, However, sildenafil has been used as a salvage therapy for severe ED at a maximum dose of 200 mg, but the incidence of side effects and discontinuation rates increase considerably. Very recent studies have reported that sildenafil does not worsen the cardiac profile of patients with ischemic heart disease, undergoing stress exercises. Sildenafil increases the time to developing symptoms of angina in symptomatic patients with ischemic heart disease undergoing a treadmill test.  Sildenafil does not cause coronary steal or reflex tachycardia.  For patients who experience an acute myocardial ischemia and who have taken sildenafil in the last 24 h, administration of nitrates should be avoided. The American College of Cardiology and the American Heart Association have published recommendations for the use of sildenafil in patients with cardiac risk. Sildenafil should be used with caution in individuals maintained on multiple antihypertensive drugs.  Adverse effects with sildenafil are dose dependent. Common adverse effects are headache (most common), flushing, rhinitis, and visual disturbance changes in the perception of color, hue, or brightness. The adverse effects are usually mild and transient, lasting a few minutes to a few hours after drug administration. It is contraindicated in patients on concurrent organic nitrates. This is because it potentiates the hypotensive action of such drugs through its effects on nitric oxide/cyclic guanosine monophosphate mechanisms.  It should be used with caution in persons with anatomical deformities of the penis (e.g., angulation, cavernosal fibrosis, Peyronie's disease), and in patients at risk for priapism (e.g., patients with sickle cell anemia, multiple myeloma, leukemia, bleeding disorders, retinitis pigmentosa). Rare side effect reported is nonarteritic ischemic optic neuropathy.
Vardenafil is given in a dose of 5-20 mg. It has mild side effects such as headache, dyspepsia, body aches, nausea, dizziness, and increased muscle enzyme creatine kinase. Individuals with blood cell disorders such as sickle cell anemia are at risk of developing priapism. It should not be taken by people taking nitrates as it can cause severe hypotension. People with QT prolongation and those on alpha blockers should avoid vardenafil. Tadalafil has much longer duration of action (36 h). The clearance is reduced in the elderly, in patients with severe renal insufficiency and in those with liver disease. It is effective irrespective of the etiology of the ED. Patients who have benefited are those who have had ED due to psychogenic causes, spinal cord injury, diabetes mellitus, and prostate surgery. Patients also benefit irrespective of age or baseline severity of ED. The magnitude of the benefit however varies. This means that it does not produce a magic erection; rather, it improves the strength of the erection, the duration of the erection, and the number of occasions on which the erection is satisfactory. Oral phentolamine and apomorphine are helpful as potency enhancers in minimal ED.  Apomorphine effects are mediated through the autonomic nervous system causing arterial vasodilation and have dopamine receptor stimulating effect. , Phentolamine decreases sympathetic stimulation and relaxes corporeal smooth muscle. 
Smooth muscle relaxants such as papaverine, phentolamine, and phenoxybenzamine are used in intracavernosal injection of vasoactive drugs techniques for ED; prostaglandin E (alprostadil) either through injection or through intraurethral insertion is an effective agent for ED. ,,, Nitric oxide beads injected into the penis have been shown to improve erectile function in animal studies and are likely to be studied on humans in near future.  A topical cream containing 3 vasoactive agents, aminophylline, isosorbide dinitrate, and co-dergocrine mesylate with or without alprostadil, is helpful in ED. An alprostadil cream and vaginally applied phentolamine are helpful for female sexual arousal disorder. Yohimbine is a central alpha 2 adrenoreceptor blocker and increases sympathetic drive. Its effectiveness is doubtful in ED. Horny Goat weed (epimedium) has been used as a traditional remedy for ED in China. Trazodone, an antidepressant, acts by inhibiting serotonin uptake and also by influencing alpha adrenergic and dopaminergic function. Results are inconsistent in erectile disorders. ,
| Pharmacotherapy for premature ejaculation|| |
Pharmacotherapy of premature ejaculation includes judicious use of tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and certain topical therapies. 
| Hormonal therapies|| |
Testosterone is definitively effective only in case of hypogonadism. It can increase the desire but has no effect on erectile functioning. Female low sex drive and anorgasmia can be tried under careful monitoring. Hormone replacement therapy with estrogen in case of menopausal women as vaginal function, particularly lubrication is determined by them. Hyperprolactinemia is treated by administration of dopaminergic drugs such as bromocriptine.
| Other drugs|| |
Naltrexone, an opiate antagonist, can antagonize the inhibition of sexual functions.  Ashwagandha, Shatavari, Korean Red Ginseng are helpful in enhancing sexual functioning in both males and females. Ashwagandha (Indian ginseng) enhances sexual desire in men. Shatavari (Asparagus racemosus), a creeper which grows in low jungle areas throughout India, is considered to be the women's equivalent to Ashwagandha and enhances female sexual functioning. Some of the traditional herbal medicines used in medieval Persia have been shown to be helpful in ED by relatively recent research. These include ginger (Zingiber officinale), almond (Amygdalus communis), spice commonly known as "grains of paradise; melegueta pepper" (Aframomum melegueta), and certain Brassica species and seed of garden cress (Lepidium spp). ,,,,, Saffron (30 mg/day) has been shown to improve sexual function (arousal, lubrication and pain domain) in females with SSRI-induced sexual dysfunction.  Snacking on pistachio nuts, 100 g/day for 3 weeks, has been shown to improve ED. 
In some selected cases when psychotherapy, behavior techniques, and drugs fail or seen to be not very effective, vacuum devices, injections and implants, vibrators are found to be relatively effective. Ultimately, the success of sex therapy depends on a host of factors. Therapy duration ranges from 6 weeks to more than a year in occasional cases. Sexual dysfunctions respond to treatment better compared to gender identify disorders and paraphilias, which are very resistant to therapy. More than half of the cases of ED and almost all the cases of premature ejaculation respond to combination of therapies.
| Conclusions|| |
- Aging typically entails some degree of change in men's and women's capacities for sexual performance from strictly physiological standpoint, yet research data suggests that an equal number of people in late life find sex satisfying, if not more so than in their youth
- It is important to recognize that older people are at risk of several health-related, psychosocial, environmental circumstances that can hinder sexual expression and functioning. Although some of these barriers cannot be prevented entirely, education, advocacy, and effective coping strategies can soften their impact considerably
- An understanding of the sexual changes that accompany normal aging may help physicians give patients realistic and encouraging advice on sexuality. Although it is important that older men and women do not fall into the psychosocial trap of expecting (or worse, trying to force) the kind and degree of sexual response characteristic of their youth, it is equally as important that they not fall prey to the negative folklore according to which decreased physical intimacy is an inevitable consequence of the passage of time
- Early adoption of healthy lifestyles may be the best approach to reducing the burden of erectile and other sexual dysfunctions on the health and well-being of elderly.
b. Sexual rights
- Sexual rights embrace human rights that are already recognized in international human rights documents and other consensus statements. They include the right of all persons, free of coercion, discrimination, and violence, to:
- The highest attainable standard of sexual health, including access to sexual and reproductive health care services;
- Seek, receive, and impart information related to sexuality;
- Respect for bodily integrity;
- Choose their partner; decide to be sexually active or not;
- Consensual sexual relations and marriage;
- Decide whether or not, and when, to have children; and
- Pursue a satisfying, safe and pleasurable sexual life.
- The responsible exercise of human rights requires that all persons respect the rights of others. 
c. Guiding principles for affirmative action:
- WHO defined the following affirmative actions in its Sexual Health Report in 2006 
- Affirmative approach to sexuality: Using an affirming approach to sexuality addresses both the pleasure and safety aspects of it and recognizes that every human being is sexual throughout the life cycle
- Autonomy and self-determination and responsiveness to changing needs: Women and men must have the right and ability to make their own free and informed choices about their sexual lives, considering their changing needs
- Comprehensive understanding of sexuality: Issues of sexuality are complex. Interventions must address and integrate emotional, psychological, and cultural factors in planning and service delivery
- Confidentiality and privacy: Sexuality touches upon intimate aspects of people's lives, where confidentiality should be maintained
- Advocacy and cultural diversity: Advocacy for the promotion of sexual health and well-being is essential for change. Programs must consider the cultural practices and beliefs in promoting sexual health. Factors such as sexual orientation, age, or disability must be taken into account
- Equity, sexual violence, and abuse: Programs and services must cater to needs that are specific to each sex and should actively redress gender imbalances through interventions that empower women to protect themselves from sexual ill-health. Sexual violence and abuse especially related to women must be addressed
- Nonjudgmental services and programs: Providers and educators must respect the values that others hold, and refrain from judging and imposing their own views upon others
- Accessible programs and services: Programs and services must be accessible, and affordable, accountable, and responsible.
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