The Meaning of the Elderly Sexuality in the Nursing Consultation Context

Renata Jabour Saraiva1, Ann Mary Machado Tinoco Feitosa Rosas2, Geilsa Soraia Cavalcanti Valente3, Ermelinda Maria Bernardo Gonçalves Marques4 1 PhD in Nursing. Assistant Teacher at Estácio de Sá University. Rio de Janeiro, Brasil. 2 PhD in Nursing. Associate Teacher in Anna Nery Nursing School/Federal University of Rio de Janeiro. Rio de Janeiro, Brasil. 3 Post-Doctor in Nursing Education. Assistant Teacher in Aurora de Afonso Costa Nursing School of Federal Fluminense University. 4 PhD, Nursing Teacher at Health SchoolPolytechnic of Guarda/Research Unit for Inland Development-Polytechnic of Guarda, Portugal


Introduction
In Brazil, is considered elderly that one that possesses 60 years-old or more.The World Health Organization (WHO) declared that in 2050, will be two billion individuals with more than 60 years-old, long-lived, becoming one of the biggest population outcome in the 21 st century [1].
However, the Brazilian Institute of Geography and Statistics [2], declared that elderly over 60 years-old totaled 23.5 million, more than double that was registered in 1991, when, in the same age group, there were 10.7 million.The participation of elderly over 65 population increased from 5.9% in 2000 to 7.4% in 2010.
It is also observed that, for the certain governmental actions effects in which regional circumstances are taken into account, it is considered an elderly person who, even though is less than 60 years-old, presents an accelerated aging process [2].
In this way, it is believed that the motivations regarding the elderly will guide the adoption of normative measures, facing the new demographic worldwide reality of the 21 st century [3].Nevertheless, it is still necessary to take into account the elderly specificities dealing with their sexuality.
For this legislator reason, entities and representatives of civil society were in São Paulo, in order to promote public health and disease prevention as to the aging process, aiming at the elderly quality of life.
The research in Portugal was intended to allow a new look at the study, taking in consideration being a country with a greater number of elderly, longlived and having a better quality of life.The data released by the last General Census of Population, promoted by the National Statistics Institute, dated March 21, 2011 (considered in this country, elderly individuals 65 years-old or older), indicates a decline in the youth population, standing at 15%, while that of the elderly increased, occupying 19% to the total population [4].
These variations result in an imbalance, which leads to a decrease in the demographic pyramid base represented by the younger population and the enlargement of its top, which retracts the elderly population growth.
The panorama of the economic and social situation in Portugal, evidenced by the census in 2011, describes that 42% of the total population was employed, 6% in the condition of unemployed and 52% in the inactivity.In the last five years, there was a decline in the age groups between the ages of 30 and 69 grew 9% and in groups over 69 yearsold in 26%.
In listening to the elderly in Brazil and Portugal, we intended to promote reflective discussions that shared experiences and existence in order to interact with the cultural plurality existing between the two countries to help understand the sexuality of this group and the possible changes in behavior acquired after implemented actions in a learning situation.Considering the need for new models in the provision of health services that enable qualified care, which will require better professional training to take care of the health of the elderly in a way that is consistent with the current reality [5].
In analyzing the statistical data, we noticed that changes in relation to elderly sexuality approach could be implemented in both Brazil and Portugal, contributing to the planning of services that meet needs, rethinking the current system and adapting it to the new realities, however, this reflection would need to be fast, as also the population aging also occurs.
This article is current and relevant due to the absence of studies in the area of comprehensive analysis on the subject of the sexuality of the elderly in the Nursing graduation, and can be evidenced through the state of the art.In this regard, we conducted a systematic review of 2,320 articles, 20 dissertations and 18 theses.Review elaborated by searching the databases of the Virtual Health Library of the BIREME system: Scientific Electronic Library Online (SCIELO); Latin American and Caribbean Literature in Health Sciences (LILACS); Online System of Search and Analysis of Medical Literature (MEDLINE); Spanish Health Sciences Bibliographical Index (IBECS); Nursing Database (BDENF); PubMed; Cochrane.
We also used the collection of the Polytechnic Institute Library and the virtual collection of libraries: Minerva As a temporal cut, the year of 1990 was covered until 2016.In the 1990 that was established due to the Organic Law of Health number 8,080/90 [6], which began the standardization of changes in care for the elderly in the health sectors, with criteria for access to the integral assistance provision with actions aimed at promoting, protecting and recovering health, aiming at maintaining and improving the functional capacity of the elderly in a multidisciplinary way of looking.
As knowledge area: nursing, education, gerontology, phenomenology.Language of selected articles: Portuguese, English, French and Spanish.For the content approach we use as keywords: nursing, consultation, gerontology, elderly, teaching, sexuality.Of the analyzed material, only one article was eligible for the study.
Most writings deal with the elderly sexuality as prevention of Sexual Transmitted Diseases (STDs), cancer and hormone replacement in elderly women [5], in which they cite that sexual function is one of the main causes of women's concern for planned hysterectomy.
The aging process requires the awareness of health professionals that the elderly is sexually active, therefore exposed to STDs, and that the issue of condom use should become a natural issue both during consultations and in groups and events organized to reach the elderly population [7].
Alencar et al [8] describe the elderly sexuality with the purpose of analyzing the factors that interfere in sexuality, performing an integrative review with publications between 2006 and October 2011, however, all focus on sexual practice, linked to myths and taboos.
The only eligible article for the study was the one that investigated the elderly sexuality [9].However, they used as methodology the Social Representations Theory.The study was performed with 30 elderly people from a Basic Family Care Unit.The data were collected in the period from March to April 2013, with the technique of free evocation word.The term "sexuality" was used as evocative.This technique allows to evidence the semantic universe of the words described by the participants of this research.
The changes in the social representations of the elderly man are being directed about self-care, and the gerontogeriatric nursing approach is a priority due to the new conceptions of old age, health care and self-care at the different stages of life cycle, together with the nurses and the health team [10].
After analyzing the samples, we observed that despite the published articles, there was a decline in the year of 2010 and a great number of publications in 2011.Regarding the level of evidence, level IV prevailed, considering descriptive studies with a qualitative approach, with the question guideline: in what way is the elderly sexuality experienced?Thus, all were excluded because they did not fulfill the study specificities and ratified the knowledge gap in relation to the presented theme.Therefore, we still need studies that reflect these differences, which permeate the life trajectories of this population despite existing legal instruments such as the Federal Constitution, Public Policies, Statutes and Reports.
Therefore, it is relevant to understand the sexuality meaning for the elderly, using specific teaching techniques, capable of generating a relationship of empathy, in order to accepting or adjusting the new lifestyle, momentary or permanent, of the current elderly [11].
The knowledge baggage about the theme of sexuality allows us to observe that the pattern of moral formation of individuals has always been seen as the guiding thread for social behavior among the various human representative society groups, this anywhere in the world, no matter the continent, country or state.This is that is known through the diverse phases of human history.
However, scientific research related to sexuality does not meet the new public policies of biopsychosocial and spiritual care, which will influence the quality of life of these elderly people [12].
For these reasons, the study gave voice to the elderly, to understand the meaning of their sexuality, in the nursing consultation context, in their new life moment.And, it aimed to understand the sexuality meaning of the elderly in the nursing consultation context.

Method
It is a qualitative research, based on the theoreticalmethodological referential of the sociological phenomenology of Alfred Schutz [13], whose importance is the use of methods that explore the maximum of the phenomena captured by the research.Their results are based on the real-life experiences of people with knowledge of the phenomenon firsthand.
Phenomenology is a significant movement, initiated by Edmund Husserl in the early 20 th century in Germany, in order to describe that all consciousness is intentional and that no objects is thinkable without reference to an act of consciousness.And that, the object presence in consciousness evidences knowledge.Thus, knowledge is explained as fulfillment of intention [14].
The consciousness intentionality becomes one of the main ideas of phenomenology, demonstrating that all consciousness is consciousness of something, and that the essence intuition is the object, the object of description on the part of consciousness, and it will be seen that there is a nucleus/central invariant structure (essence), which remains throughout all imaginary variations.
However, Husserl's goal, according to Schutz [13], was to establish the creation of a philosophy without presuppositions.Opting for this, to study the experiences of the conscious human being who lives and acts in a world, where he perceives and interprets the phenomena, so that it is possible to make sense of it.
Considering the specificity of the thematic, it was chosen to make use of the Sociological Phenomenology of Alfred Schutz, to articulate with the article.For this, it was necessary to listen to the elderly, seeking their intentionality about their sexuality, through the contextualization of the reason-why, with the intention of understanding the actions that impelled the planning and execution of singular activities for each subject of this process.
The study was based on the dependencies of the Health Care Institution São Francisco de Assis (HESFA) -UFRJ, which works with the teaching of nursing consultation to the elderly, located in the city of Rio de Janeiro.As a complement to the study scenario, there were data collection in Portugal, in three Day Centers; a Conviviality Center; a Mixed Unit with Day and Home Center; a Family Care Unit, a Health Center; a Hospital and a Senior Academy in the Guarda City, Portugal.
There institutions are based on the Official Body -Social security, with the purpose of obtaining answers of social support for elderly people, whose objectives are to promote autonomy, social integration and health.
There institutions are used as a scenario of practical activities for the students of the Health School of Guarda -Guarda Plytechnic Institute.Data  The choice is justified because they are institutions that adopt teaching dynamics and consultations, making it possible to show the intentionality of the nursing and teaching nurse action, making use of multidisciplinary and being an elderly care reference.
Forty-one elderly people who participated in the nursing consultation program, took part in the study.As inclusion criterion, the following were considered: aged 60 and over, active, open to new technological trends that facilitated their daily life, able to accept their new way of life, participating in individual and group activity programs in there searched scenarios and wishing to talk about their sexuality.
As an exclusion criterion: the elderly who were not present on the interview day and because they did not have available time.The elderly was identified by the alphabetic letters: I (elderly plus the alphabetic letter, in Portuguese).In this way, they were interviewed individually, by electronic recording (MP3).As a reliability criterion, it was allowed to listen to his interview record later.
For the data collection, the interview with a phenomenological approach, semi-structured, with an initial script, in which it was possible to understand the typical phenomena of the research participants.The questions used were: How do you experience your sexuality: And what do you have in mind when you come to the nursing consultation and talk about your sexuality?
It was understood from Schutz [13], that the participants' intentionality and the subjectivity and intersubjectivity understanding provided by the empathy of the face-to-face relationship, demonstrated at the time of the interviews, gave rise to the natural genuine phenomena of human relations, without take into account their values, providing an understanding of the contextualization of the reason-why and its categories.
For the data organization, aiming to reach at the typical of the subject's action, the phenomenological methodological trajectory of Alfred Schutz's theory [13] was used, range the following steps: apprehension of the speeches in the interviews, to describe the lived type of subjects; immediate transcription of the interviews, excluding Portuguese erros, aiming at preserving the subjectivity of the face-to-face research-participant relationship of the study; attentive and meticulous reading, to transform what has proved subjective in objective, with the purpose of grouping the meanings found into categories; cognomens used to express meanings, and to maintain anonymity; and the intentionality of the participants lived type, through reasons-for and reasons-why.
This attitude represents the researcher's own activity in identifying, from the lines, the elaboration of concrete categories of the lived.Therefore, the typicality opens and closes according to the level of anonymity and familiarity [13].
In order to make it possible to obtain different meanings, the research typology used, based on the phenomenological methodological trajectory of Alfred Schutz's theory, presents as analysis and interpretation, categories that will vary according to the intersubjectivity of each researcher.The speeches of the research participants will be stored for a period of five years and discarded afterwards, respecting human opinion and dignity, involving the current and potential progress of science and technology, which should result in promotion of the well-being and de quality of life, as well as the defense and the preservation of the environment, for the present, as well as for the future generations.

Results
Regarding the participants' gender, 17 elderlies were male and 24 were female in the age group between 63 and 92 years-old.
As for naturalness: 07 born in Rio de Janeiro, 01 in Bahia, 01 in Minas Gerais and 32 in cities of Guarda District, Portugal.(Figure 1) In relation to the marital status: 04 singles, 19 married, 03 separated and 15 widowed.Level of instruction: 02 without education, only 01 with complete college education, 01 with incomplete college education, 01 with complete high school, 03 with incomplete high school, 14 with incomplete elementary school, and 19 with complete elementary school.(Figure 2, 3) As for the beginning of the sexual life: 02 still did not have sexual relation, the rest with age group between 17 and 29 years-old.Regarding the onset of menarche or menopause, all reported needing a significant act, so they could remember an approximate date to answer the question, and it was evidenced that they present a normal physiological process, most of the process of aging in this phase of life, and that there was no gender difference among the elderly.It was proved from the results that the relationship of space and time established between the research participants and the interviewer revealed the contextualization of "reasons-why" categories.
However, in order to reach at this methodological behavior, it is necessary to seek the foundation of Schutz's concept of the "reason-for", in which the intention of the projected act must be realized by a future action.

Discussion
Thus, through the phenomenon itself, emerges after the comprehensive analysis, the categories: Preconceived ideas between nurses and the elderly; Interpretations about sexuality and sex between nurses and elderly; Cultural aspects involved between nurses and the elderly.
After the speeches analysis, it was possible to understand the meaning of the elderly in the educational action on the sexuality of the elderly in the nursing consultation context.Making the "reasonwhy" of the study emerges: a description of preconceived ideas and the lack of understanding of sexuality of the elderly, and the influence of the cultural aspects involved in the nursing consultation context.

Preconceived ideas between nurses and the elderly
The elderly statements described below, prove that there is no gender inequality, social and cultural position among them.
Subjectivity and intersubjectivity are present at the moment when the elderly inform not to be approached on the sexuality subject and have the will to speak.
They never asked about my sexuality.You're the first person to ask me.I've had an interview with a girl here, but they never touched on that.I would respond without problems […].[…] people are deluded when we reach the age of fifty, men have drank, smoked and made "hot", start looking for younger women because their wife is no good anymore.(I-D) Thus, the intentionality of the educational action of the nurse or other health professional, in the presence of some elderly people, should mediate the process in relation to the subject, creating the possibility of acquiring new skills to reflect and create new meaning, since individuals acquire new knowledge or skills by modifying their thoughts, feelings, attitudes and actions [15].

Sexuality and sex interpretations between nurses and the elderly
Sexuality encompasses more than the physical ability to have sexual intercourse.However, after the immersion of the interviews, we identified that the meaning of the words "sexuality" and "sex" still persists.However, those who know this complexity because of preconceived ideas cannot put it into practice.
In the elderly case, there is a lack of information about the sexuality interpretation, when they are motivated, they come to understand and feel more comfortable in accepting the limitations of the aging process.
We have other ways, we caress.That kind of thing, right![…] Old man, no!I'm elderly!Because old is the one who already bows his head and is already waiting […] Now I do not!I still think, I still have life project, I still think that tomorrow I can go there.I can do something else.Now the old man does not!The old man has died in the spirit in everything.Now I think not yet!(I-AU) The elderly being encouraged to talk about sexuality and sex, express their desires, affections, dreams and forgotten romanticisms over time and with the natural frustrations of the aging process.With the motivation, they showed interest in discussing the subject and understanding regarding the physiological change that relates to the sexual desire.They came to realize that sex is part of sexuality, but they understood that sexuality also includes expressing oneself and being perceived as male and female.
The elderly, due to various circumstances (widowhood, retirement, socioeconomic changes, unresolved griefs among others), modify their way of living [16].Feelings and behaviors influence and are influenced by everything around the individual, because the environmental components can encourage or discourage social and mental activities, which has been called respect for the stock of experiences at hand, to which our knowledge of the world belongs that we live [13].

Cultural aspects involved between nurses and the elderly
To understand the similarities of the study participants' behavior, we cannot forget the cultural existence initiated by our own Portuguese language.In addition, due to our colonization, we inherited other traditions, such as the Catholic religion, the religious calendar, the cuisine, as well as important festivals such as the Carnival and the June festivities.All these similarities can be understood as the world of the natural attitude.There is a parallel with colonization, the world of daily life, considered as an intersubjective world, which existed long before our birth and has already been tried and interpreted by our predecessors [13].
From the speeches analysis, we understand the stock of experiences by hand of the world in which we live, it is the elderly life baggage.
I understand that it is being caring with each other, caring, having no clutter with anyone.Thank God I have it all!I always liked to take a shower!I like to put my handkerchief on because the hair burns all over, and then it does not hold.[the old woman claps her hands, smiles and says].That's how I was raised.There was a time that did not wear a scarf, but then I had an illness that started to plague my hair!(I-AK) The speeches refer us to a contextualization of hopelessness, since throughout the elderly people's life accumulate several unclosed mourning.Moreover, the subjectivity of the mourning meaning is unique.Although it is more common to associate mourning with the death of a loved one, when there are other possibilities.
The elderly intentionality is found in the intersubjectivity of relationships, but for this, it is necessary to exchange and share ideas [13].Therefore, intentionality about the sexuality educational action of the elderly, in the nursing consultation context, is shown for those people who understand and share them, seeking the coherent interpretation of the nurses between sexuality and sex in relation to the elderly, with the acceptance of approach as the normal attitude of aging process.

Conclusion
After studying elderly data, it was verified that because they were not approached about sexuality in the consultation context, the absence of a correct interpretation between the meaning of sexuality and sex, contributes to the understanding of preventive clinical care of the nurses, only in relation to the pathologies sex-related.
The elderly confirmed that nurses never ask about their sexuality.Because it does not occur to health education about the sexuality complexity, and that sex is part of this whole, is the first moment, they report that sex changes with age, or no longer have sex.
However, when motivated by the questions of the script of semi-structured questions, they demonstrated a sexuality understanding as affective relationships that provide quality of life.Thus, it appeared as a definition for the elderly: the biomedical paradigm approach, based on humanization and biopsychosocial understanding on the elderly sexuality, with the intention to providing an active quality of life.
The study development met the standards according to Resolution 466/12, the research participants signed the Term of Free and Informed Consent.The interviews were carried out with the approval of the Ethics and Research Committee (CEP) of the Anna Nery Nursing School -Federal University of Rio de Janeiro, on November 13, 2014, under the number: 1,696,419.

Figure 3 :
Figure 3: Begnning of the sexual life of the elderly by gender.Rio de Janeiro, RJ, Brasil, Portugal, PT, 2014.
collection in Brazil took place in the outpatients of the São Francisco de Assis Health Care Institute, in which some Health Programs of the Basic Care Unit (UCB) are developed, such as: Gynecological Nursing Consultation; Women Nursing Consultation in the Climacteric Period and Menopause; Comprehensive Assistance Program for the Elderly (PAIPI); Comprehensive Care for HIV/AIDS Program, linked to the Specialized Attention Service (SAE) and the Center for Testing and Counseling (CTA), and Center for Teaching, Research and Reference in Alcoholology and Adictology (CEPRAL).