GRANDMA AND GRANDPA ALSO LOVE: SEXUALITY IN THE ELDERLY VOVÓ E VOVÔ TAMBÉM AMAM: SEXUALIDADE NA TERCEIRA IDADE LOS ABUELOS TAMBIÉN SE AMAN: SEXUALIDAD EN LA TERCERA EDAD

This study aimed to analyze the professional practice of doctors and nurses in the Family Health Strategy in relation to aspects of sexuality in the elderly. This was an exploratory study with a qualitative approach based on participant observation and semi-structured interview, conducted in six teams of the Family Health Strategy in the municipality of Crato-CE, Brazil, from May of 2013 to May of 2014. A total of 12 professionals, six doctors and six nurses, participated in the study. The data collected were organized into four explanatory categories and analyzed in an inductively and interpretative way. The results reveal the meaning given by professionals to sexuality in the old age, the ways in which professionals identify sexual needs, the approach on sexual needs in the elderly, and actions on the quality of sexual life. It was found that the subject was difficult to approach during consultations, although relevant in the context of health facilities. The data also highlight the lack of actions focused on this theme in health units, signaling great weaknesses with respect to a comprehensive health care for the elderly.


INTRODUCTION
Aging is an organic process inherent to the human existence, which brings biological, psychosocial, and cultural changes.However, while senescence is a biological process, each person ages individually, which implies in personalized attention from health professionals to clients in this age group.
The global elderly population has grown in the last decades of the twentieth century.In 2012, the number of elderly people reached 810 million.It is expected that by 2050 the world's elderly population will correspond to more than two billion people. 1 In Brazil, this population appears to be growing, mainly due to demographic and epidemiological transformations that have occurred in recent years, reduced fertility and mortality and increased life expectancy.The intensification of the proportion of elderlies in the Brazilian population has been observed, and a population of 63 million people in the old age is estimated for the year 2050. 2 In Brazil, there was an increase in life expectancy from 66.5 years in 1990 to 71.7 years in 2006, in both genders 3 , although regional and gender differences are observed in these statistics due in part to the very evident social inequalities in developing countries.
According to the 2010 census, 11% of the Brazilian population was elderly.Ceará ranked seventh among Brazilian states in the number of people aged over 60 years (11.2%), which is a proportion higher than that in the Northeastern states (6.5%).The largest population was concentrated in Rio Grande do Sul (13.8%). 4rowing old is a sequential, individual, cumulative, irreversible, and non-pathological process of deterioration of a mature organism, natural to all members of a species, that leads to lesser abilities to cope with stress in the environment and, therefore, increased possibility of death.Thus, the Western society simplifies the aging process with negative stereotypes and prejudices, featuring the elderly as an inert being. 2 Sexuality is inserted this context of stereotypes.
These assertions are echoed in the understanding of sexuality that the Brazilian society has learned to legitimize, whose historical foundation is based on the appreciation of sex as a secret, with a strong repressive component and enhancement of physical/biological aspects with an expressive essentialist speech. 5However, it is essential that the cultural and human perspectives be included in this category because, in contemporary times, the theme of sexuality is still sometimes delicate and of difficult approach. 6exual banning for the elderly is, even more, prominent and part of collective and medical representations in the Brazilian society.Thus, from a historical point of view, in the decade of 1935, doctor Sebastião Mascarenhas Barroso launched the book: "Sexual education, a guide for parents and teachers, what they need to know, how to teach."His teachings included: avoid wrongful and inconvenient acts to health and moral up to 12 years of age; from 12 to 18 years of age addictions and aberrations of the genitals and sexually transmitted diseases (STDs) should be avoided, and eugenic rules in the union of parents should be observed; and for the elderly, sexual abstinence. 7herefore, a study conducted with elderlies on aspects related to sexuality revealed that the acceptance of the various changes occurring in the aging process, such as biological, psychological, and social, related to the sexuality process, depends on how the elderly deal with these changes. 8These results may be related to the activities that these people perform, and their life stories, which can help offset these changes and lead them to be more active.
Concerns about aging with the quality of life gained relevance, specifically in the last 30 years.This fact is due to the increasing number of elderlies and the observation of increased longevity in most societies, leading authorities and scientists to elaborate plans based on these studies. 9rofessionals in the Family Health Strategy (ESF) do not practice discussing issues related to sexuality and sexual practices with patients during consultations.This tension is higher when they are elderlies by believing that sex is not in the reality of this population. 10,11This arises because health care is performed with a focus on complaints or diseases, which is the curative vision of the health-disease process.
For this reason, the approach to sexuality is often absent, which does not allow the prevention of common diseases in this age group, such as erectile dysfunction, vaginismus, dyspareunia, inappropriate use of certain drugs, and the prevention of AIDS; thereby, not promoting health in these group in order to guarantee an improved quality of life and well-being. 11,12he ESF is an alternative for overcoming the dominant paradigm in the field of health because it proposes changes in the design of the health-disease process, moving away from the traditional model that is centered on offering services geared toward diseases.It also invests in actions that link health with living conditions and quality of life. 13his approach should be implemented in all age groups, highlighting the aging population 10 as the fastest growing population group in Brazil showing increased demand for health and social problems, requiring expanded professional assistance that considers elderlies as whole individuals, taking into account limitations, concerns, and the environment in which they are inserted.
In keeping with these exposed ideas, we believe to be of fundamental importance to focus on the performance of doctors and nurses in the perception, understanding, and implementation of actions to support elderlies to understand and experience sexuality as best as possible, seeking from these ESF professionals closeness to the implemented health actions.and the facilities, difficulties, and challenges identified.The information obtained during the interviews was audio recorded.
Once recorded, the testimonies were transcribed and checked for fidelity through an inductively interpretative analysis.The main meanings in each paragraph of the interviews were identified and assigned a certain category.The explanatory categories were presented and the meanings were exemplified through excerpts from the testimonies.
The organization of empirical data was performed by compiling the set of data from different sources (field diary and interviews) and different professionals (doctors and nurses); comparison, first by professional and second by their combination, and between interviews and field observation records, detecting homologies and specificities in the material set were conducted. 17The interpretative synthesis of organized groups of data was produced based on a dialogue with the literature.
The study complied with all formal recommendations arising from Resolution No. 466/12 of the National Council of Health 18 , referring to studies involving humans.This resolution incorporates the perspective of the individual and communities, the four basic principles of bioethics: autonomy, justice, beneficence, and non-maleficence, guaranteeing the rights and duties of the State, the scientific community, and research participants.Therefore, participants signed the Voluntary Informed Consent Form (TCLE).The names of participants were replaced by their respective professional categories preceded by ordinal numbers.The present study was submitted to the Research Ethics Committee of the Regional University of Cariri and approved under Opinion No. 139/2011 of 2012.

Char acterization of professionals
Out of the surveyed professionals, three were men and nine were women, with a mean age of 34. 1 years, ranging from 24-52 years old.
Nine declared themselves as Catholics, one spiritualist, and two did not follow any religion.The professional training time averaged 7.6 years, ranging from seven months to 27 years.None of the doctors had a specialization training, and all nurses had some specialization training, the most frequent being specialization in Family Health.

The work of doctors and nurses in the Family Health Units
The activity schedule for doctors and nurses was posted on each unit showing the weekdays for each type of assistance, prioritizing the days of hypertension and diabetes due to a These actions aim to promote sexual quality in the elderly in seeking to identify from them the indicators of facilitators, potentiality, and difficulties in this area.
Hence, this study aimed to analyze the professional practice of doctors and nurses in ESFs regarding aspects of sexuality in the elderly population.

METHOD
This was an exploratory study with a qualitative approach, conducted in the municipality of Crato, CE, Brazil, in local Family Health Units, which featured 31 teams and 87.15% of the covered area. 14A total of 13,855 people is registered in the ESF in 2014 as over 60 years old.Of these, the majority were women, with a percentage of 58.4%. 15ix ESFs located in two health units were surveyed, which had more than one working team and considering conditions for access and affordability for data collection, the presence of a doctor and nurse, and location in the urban area of the municipality.Health units were selected considering the larger number of elderlies enrolled in the municipal primary care.Six doctors and six nurses participated in the study; dentists were excluded based on their roles linked to oral health actions in the ESF and according to Annex I of Ordinance No. 648/GM of March 28, 2006. 16he inclusion criteria were: working in the selected ESF for at least six months, and assisting elderlies individually or collectively.The exclusion criteria were: professionals who were absent from their work activities for more than 15 consecutive days, for whatever reason, or have been replaced or transferred from the selected ESF during the data collection period.However, there was no excluded participant.
The instruments used to guide the data collection were participant observation and a semi-structured interview.Field observations lasted three months and allowed following consultations with doctors and nurses.These observations occurred three to four days a week in the mornings; one week in each ESF.
This theoretical and methodological approach was adopted to enable the investigation of what goes beyond what is documented, said, and written.However, because this practice is exercised within the care processes in the health production system, and the dynamics of relationships and actions that support the daily life and cultural meanings of the people investigated, we used a field diary to record the activities of the selected professionals.
The interview was applied individually, addressing aspects related to the work process aimed at implementing health actions related to matters of sexuality in the elderly, emphasizing the importance of addressing this theme during the professional practice, the strategies used to carry out this practice, large number of users with these conditions.Complaints related to sexuality were possible on days of spontaneous demand.
These professionals assisted an average of 12 patients per morning.The consultations lasted around 10-15 minutes.During the observations, it was clear that the consultations in early mornings lasted longer than those at the end of the morning period, which were faster and less detailed.A difference in consultation time between male and female elderlies was observed.The consultations were longer with female elderlies because they had more questions and complaints and liked to talk.The consultations with male elderlies were always directed to the disease because they are shy.Because they showed no interest in discussing or questioning sexual life, the professionals did not instigate possible questions on this issue, which resulted in no dialogue between professionals/users.
The priority on physical examination and well-detailed anamnesis were present in all followed-up consultations.Little or nothing was said about sexuality during consultations.When discussed, the speech was superficial and almost always focused on questions related to the examination of the prostate-specific antigen (PSA) and prevention of prostate cancer for men.

The pr actice of doctors and nurses in the ESF regarding aspects of sexuality in the elderly
The empirical data, collected through the interviews and observation, produced four categories: the approach of sexuality in old age; identification of sexual needs; fulfillment of sexual needs; and actions on the quality of sexual life.
The first category refers to the perception of each professional on the theme "Sexuality in old age."Professionals highlighted the importance of this theme in the context of the Family Health units, mainly due to the increased incidence of STD/AIDS in this population.However, they reported difficulties in addressing the issue during the consultations, related to the discomfort that elderlies felt when the subject was brought up and because it is still a controversial issue, surrounded by myths, taboos, and prejudices.However, they stated feeling more comfortable in proceeding with these discussions with women than with men.

It is a difficult theme to address because the majority of older people are quite closed, mostly men […] is important not to be passed up […] we should provide guidance on prevention because HIV infection in old age is increasing (Doctor 11).
We have some difficulty in addressing sexuality in old age, not only professionally, but also at the user level, the elderly, due to taboo and prejudice […] (Nurse 10).

In fact, it is hard to know how to talk to them (the elderly), especially with men […] (Nurse 4).
The second category refers to the identification of sexual needs in the elderly and how these professionals identified that the elderly had any need linked to sexuality.
Many professionals could not discuss matters related to sexuality and waited the user to bring up a complaint in order to discuss the matter.It was easier for the nursing professionals to approach this dimension during the examination of gynecological cancer in women because then they could expose questions and complaints.
Many elderlies ended up not reporting complaints during consultations because many felt embarrassed to talk about sexuality.Thus, the professionals used anamnesis and physical examination as strategies to identify this need and define actions.

I confess that I never questioned about it. I let everyone at ease. If they have any question then I talk […] (Doctor 7). I talk about it. Especially with women and about prevention because we always address this […] (Nurse 2). […] During the anamnesis, they end up reporting some related problem (Nurse 9).
The third category of the professional assistance is inherent to the sexual needs of older people.There was disagreement among meeting these needs between doctors and nurses.Doctors were focused on the curative aspect of sexuality-related issues, for the treatment of diseases.Nursing professionals recognized sexuality subjectively, prioritizing doubts and questions, serving those needs through dialogue and guidelines.

In my case it is only treatment […] (Doctor 6). I listen, guide, we have the issue of dialogue between us and, in this dialogue, we try to figure out what's really going on […] (Nurse 10).
Another important issue was the referrals in which both professionals, because some are problems related to hormonal issues such as menopause, and erectile dysfunction would refer these users to more specialized assistance where they would receive support from trained professionals.

Well, I hear the complaints, answer within the aspect that she understands […] what I can and what I know
Among the factors contributing to the increase of STD/ AIDS among the elderly, the lack of strategies and guidelines that prioritize the prevention of diseases in primary care in this group, and difficulties that older people face in using condoms are highlighted.However, these factors highlight the weaknesses of health strategies before the elderly vulnerability to these health issues. 22n the ESF scenario, the reports about difficulties addressing aspects of sexuality in the elderly during consultations demonstrate an erroneous view on the subject when the focus of attention is directed to genitality and sexual intercourse.Sexuality is not limited to intercourse, the sexual act, with the sole purpose of procreation.It goes much further; it deals with subjectivity, touch, communication, and love between two people as a form of knowledge of their own body and the body of another. 23hus, the ESF is not intended only for curative actions and disease prevention, but mainly for the promotion of health and improvement of quality of life, focusing on the individual, family, and community regarding health care.Elderly care is happening in a fragmented and isolated manner, focused on the treatment and recovery of certain health problems, especially based on the demands coming from the Hypertension and Diabetes Program (Hiperdia). 24he Hiperdia is a health program that facilitates the interaction between professionals and users.Although hypertension and diabetes are comorbidities that require intensive evaluation and observation, the professional needs to expand the vision beyond chronic degenerative diseases and thereby, guide the practice in its entirety, with a positive impact on the quality of life and successful aging.
The individualized consultation was the main instrument used during assistance allowing embracement, qualified listening, expanded view, and comprehensiveness to be in the background of the professional work with the elderly.This passive attitude keeps the health care guided by the curative-based perspective. 24exuality in this age group is not discussed and is often even ignored.The elderly must be seen as people who have sexual wants and needs. 21However, it is necessary to adopt health policies geared to the elderly and implement prevention programs for this population's sexuality in which health professionals become capable of deconstructing the myths, taboos, and prejudices surrounding this public.
Therefore, primary care professionals need to develop strategies guided in the connection and interaction between professional/user.With this interaction, the overcoming of constraints when talking about sexuality with elderlies could take place.Professionals need to be trained to be able to assist the elderlies' health in an integral and equitable way.In this study, the primary care professionals indicated that training in health care for the elderly is an effective care strategy.

within my knowledge, I guide, and I refer her to a gynecologist […] (Nurse 12).
The last category corresponds to actions that professionals at the ESFs execute towards the quality of sexual life in the elderly.All respondents did not carry out specific actions for this purpose.This lack of action has occurred for reasons explained by the professionals: the elderlies' disinterest in talking about sexuality, lack of training for professionals to work with the theme, and limited availability of time and professionals.

DISCUSSION
The Ministry of Health defines sexuality as "a set of human characteristics that translates in different ways to express the vital energy". 19It includes the dimensions of the body materiality, involves feelings, affectivity, and customs expressed from birth to end of life of an individual, and should not be confused with the sexual act itself. 20owever, for a society that prefers to think of elderlies as asexual beings, and not recognize them as a vulnerable population, the issue becomes dispensable for health professionals, making it difficult to implement preventive actions and promoting sexual health. 21However, assessing the sexuality of this population may be the appropriate strategy for the creation of measures that can minimize the exposure of elderlies because the absence of information may be responsible for the upsurge in STD/AIDS rates in this group.
Over time, the demographic transition is altering the reality of the social scene of humanity and, with it, longevity brings triggering factors with significant structural changes.The aging of the population is related to the increase in life expectancy and, therefore, chronic degenerative diseases that are relevant to the social structure emerge.
In the scenario of diseases that affect the elderly, the emphasis is given to the increased incidence of STD/AIDS in this population because the number of AIDS cases increases with the increase of elderly populations.The problem of aging and AIDS in Brazil is not just a cultural issue, but also a matter of exclusion, which highlights the social prejudice related to sex in this age. 21here is great urgency in professional training for gerontological and geriatric care.Thus, if there are no professionals able to work with the health of the elderly within the basic unit, there is no comprehensive care as dictate by the guidelines of the Brazilian Unified Health System. 11,12t was observed that the elderly assistance provided by the professionals evaluated in this study was focused on complaints at the time of consultations in the health service.The development of educational work, which are individual or in groups, qualified listening, and socio epidemiologic knowledge in the area of expertise compose a strategy that qualifies and extends the health practices. 24With this, the importance of developing educational activities with the elderly is recognized because of the primary focused on hypertension and diabetes, and often limited to the prescription of drugs, with limited space for other demands. 25

FINAL CONSIDER ATIONS
The way professionals approach sexuality issues with the elderly is still focused on the speech of difficulties in handling this issue within the health unit resulting from factors related to the body's own prejudices and myths that surround this subject.
To carry out a comprehensive health care for the elderly and improve the quality of life of this population, these professionals should be able to work and develop specific actions related to sexual health in this population.However, the interviewed professionals in the basic attention units could not develop a specific action, directing the consultations towards complaints and treatment of diseases.
The limitations of this study can be explored in new studies and the development of activities on the theme "Sexuality in the old age" within health units and along with their professionals in order to make this subject widespread and qualified among professionals working in the primary health care, and consequently, improve the public health.