Breaking down taboos concerning sexuality among the elderly

Sexuality as a human need for belonging and being close with someone, as a need for affiliation and physical pleasure is typical for all ages in the life span development [1]. In regard to human needs sexuality is a goal (the need) and a mean through which individuals satisfy their needs. Sexuality has a significant impact on individual's self-esteem, well-being, and functioning; it includes personal, cultural and social identity, and not just sexual orientation and behaviour [2]. The need for sexuality and intimacy is maintained in old age [3], only modes of sexual expression can be different concerning individual's age. In addition to physical sexual relations elderly can express sexuality through hugging, fondling, kissing, holding hands, touching or physical closeness [3, 4], through demonstrating mutual tenderness, support, and under‐ standing, and through developing a new partnership relationship [5].


Introduction
Sexuality as a human need for belonging and being close with someone, as a need for affiliation and physical pleasure is typical for all ages in the life span development [1]. In regard to human needs sexuality is a goal (the need) and a mean through which individuals satisfy their needs. Sexuality has a significant impact on individual's self-esteem, well-being, and functioning; it includes personal, cultural and social identity, and not just sexual orientation and behaviour [2]. The need for sexuality and intimacy is maintained in old age [3], only modes of sexual expression can be different concerning individual's age. In addition to physical sexual relations elderly can express sexuality through hugging, fondling, kissing, holding hands, touching or physical closeness [3,4], through demonstrating mutual tenderness, support, and understanding, and through developing a new partnership relationship [5].
There are many factors that positively or negatively affect the expression of sexuality among elderly in nursing homes. Not only age-related changes and diseases [6] but also some psychosocial factor occurs. Skoberne [7] and Ziherl [6] argues, that these factors are widowhood, separations, quality of partnership, self-esteem, health impact on partnership, economic situation and environmental influence. In fact, sometimes is easier to influence on age-related changes and disease than environmental influence which has a significant impact on satisfaction of sexual needs in older age. Moreover, in this case the environmental influence means other people views whether are already so deeply entrenched and changing them can be very time consuming process. Society still perceives older people without sexual needs or incapable of sexual activity. For that reason elderly suppress their sexual needs and start to behave in accordance with these beliefs [7].
Institutional care is important and widespread form of care for the elderly who are no longer able to live independently. The attitude of nursing staff towards sexuality is very different and may vary from positive to negative or permissive and restrictive [8]. This can significantly inhibit the expression of sexuality among the elderly. Room designs which do not provide privacy [9], taking care just for the physical needs, avoid talking about sexuality because of the shame [1,10,11], failure to respect residents autonomy or the need to control their behavior [3], and letting families to take decisions instead of them [12] are the aspects which may have a significant impact on sexual or intimacy expression among elderly living in nursing homes. Moreover, nursing staffs day-to-day contact with residents often develops into strong relationships, which also affect the sexual expression of the elderly in nursing homes [13]. Since satisfaction of needs has an important role in individual's satisfaction, happiness, and wellbeing, the study of nursing care professionals' attitudes toward sexuality and sexual needs of elderly is necessary for a comprehensive understanding of the determinants which influences the quality of life among elderly in nursing homes. In the end of the chapter authors present the results of a study of nursing care professionals' attitudes toward sexuality of elderly in nursing homes which was performed on a sample of nursing staff from 5 Slovenian nursing homes. The authors developed a semantic differential scale, encompassing a list of adjectives, through which nursing care professionals described the meaning attached to sexuality of elderly in institutional care.

Physiological and psychosocial aspects of sexuality among elderly
Older people continue to have need for maintaining their sexual activity and intimacy [3], they just change the ways of expression of their needs. However, in addition to physical sexuality, elderly express their sexuality also with hugging, caresses, kissing, holding hands, touching or by physical closeness [3,4] as well as tenderness, partners support and mutual understanding [5]. There are many factors that positively or negatively affect the expression of sexuality among elderly which include not only age-related changes and diseases [6] but also some psychosocial factors.
Over the years, some physiological changes occur in aged population that affects their sexual activity. For example, men take longer to get an erection, which can be shorter, and women can perceive physiological changes as a vagina moistening problem. However, Walsh and Berman [14] observed that with age the desire for sexual activity and the possibility of experiencing orgasm do not decrease. Although, in the recent years, studies that describe sexual lives among older women become more frequently, we still trace down some prejudices that with the menopause sexual life is over or that sexuality during menopause is not appropriate [15].
The level of estrogen in women after menopause is declining, but the body still produces enough testosterone to maintain interest in sex [15,16]. Some women after 60 years may experience that the clitoris is somewhat reduced, but still remains very sensitive [17]. Also, due to dryness and vaginal atrophy women can experience pain during sexual intercourse (dyspareunia) [16]. Sexual excitement can be reduced or it is weaker, and therefore women require a longer petting to lead her to an orgasm [15]. There also may be some psychological symptoms that accompany menopause. The fact that women in menopause cannot have children any more, for some proves the inevitable aging [14,18]. Distress in older women is also caused by other factors including urinary incontinence, removal of the uterus and some other chronic diseases [19], although the removal of the uterus usually does not affect sexual satisfaction [16]. However, all this have an impact not only on the sexual functioning, but also on emotional state, self-esteem and consequently interpersonal relationship [20].
Even older men are confronted with some changes that may affect the perception of sexuality and sexual desire, although most of them produce enough testosterone that is sufficient to maintain libido [16]. The most common sexual dysfunction in man is erectile dysfunction and hypogonadism [20]. In fact, erectile dysfunction in man increases with each decade, starting at age 60 [21]. Masters and Johnson [17] found that men aged between 50 and 90 years, usually state that their erection is slow and incomplete, and for its maintenance need more stimulation. In older men the stimulation should be of both, mental and physical nature in contrast to younger men which mostly require only mental stimulation. On the other hand, older men have the ability to have greater control over ejaculation, but the intensity and volume of ejaculate is smaller [22]. Same authors also indicate a shorter orgasms and prolonged interval between each ejaculation. For those aged more than 70 the interval can be extended up to 48 hours [16], but it rarely happens that a sex organ is completely unresponsive [23]. Even some health problems and chronic diseases may affect the sexual performance in older man. Diabetes, vascular disease, fear of heart attack, certain operations (for example prostatic surgery) and some medications (used to treat hypertension, depression, anxiety, cancer etc.) can affect sexual desire or ability to have sexual intercourse [14,23]. Table 1 presents some of the key changes among elderly man and woman that affect their sexuality and sexual functioning.

Physiological changes in men
Physiological changes in women Sexuality among elderly has also some advantages. Master and Johnson [17] have stated that one of the advantages of aging, according to the sexual functioning is that the control of ejaculation in the man aged 50 to 70 is better than in man aged between 20 to 40. In other words, many older people retain the ejaculation longer and therefore the sexual intercourse last longer to orgasm. Furthermore, women are no longer afraid to become pregnant [23] and they no longer need the contraceptives, which can release libido and lead to an increased desire for sexual contact [18].
But in spite of this society still perceives older people without sexual needs or incapable of sexual activity. For that reason elderly suppress their sexual needs and start to behave in accordance with these beliefs [7]. Lindau et al. [24] found, that sexual desire and activity are widespread among elderly man and women; however those aged more than 70 placed less importance on sex than the younger population [25]. The same authors also found that there are some gender differences in attitudes toward sexuality, with the greatest difference being in the older age group (41,2 % of males aged 75 -85 stated an interest in sex compared with 11,4 % of females of same age) [24]. Other studies also shown that not having sexual partner and having poor health status in the late period of life are associated with decreased sexual activity [26,27], but this does not necessarily mean that sexuality is not important to older people. In fact, Gott et al. [25] found that only when the barriers to remain sexually active were too great to be overcome then sex assume no importance, regardless of age.
Psychological aspect may be as important as physiological aspect for sexual function because this aspect can impact the ways in which other determinants of sexual function are expressed [28,29]. For example, emotional and interpersonal motivation mediates the effect of sexual desire which is produced by neuroendocrine mechanisms. In fact, motivation plays an important role regarding personal attitudes about sexuality [28] and in sexual functioning of the person because it may increase the desire for sexuality and affects on sexual inactivity due anxiety, or anger with partner [30]. Psychological problem such as depression also influence sexual function in all age group. Its pharmacological treatment is associated with sexual dysfunctions such as anorgasmia, erectile dysfunction, diminished libido that may persist even after medication use is discontinued [31]. However, sexual dysfunction in depressed older adults is often overlooked and less appropriately treated than in younger population [20]. Moreover, psychological aspect is independently related to sexual function. Self-perception theory argues that individuals make attributions about their own attitudes, feelings, and behaviors by relying on their observations of external behaviors and the circumstances in which those behaviors occur [30]. Self-perception theory can be applied to a situation in which a woman observes that she is receptive to her partner sexual initiations, but she is never the initiator. Consequently, the woman perceives that because she engages in sexual activity only in response to her partner, she has low sexual desire [16]. Also, many women because of selfperception theory and overjustification, experience sex as an obligation rather than as an enjoyable part of the relationship, and they consider themselves sexually inadequate. Low selfesteem or poor body image due to aging is also an important psychological barrier which affects the sexual activity of older adults [17]. Furthermore, many couples in long-term relationship perceive the natural decrease in excitement and passion as a symptom of failed marriage. But in every long-term relationship passion can decline over the time and comfort, security, and partnership step in [28]. In addition, relationship duration may affect sexual frequency. Call et al. [32] found that the habituation to sex occurred as relationship duration increased, resulting in a decline in sexual frequency. However, sexual frequency decline is not synonymous with the decline in sexual satisfaction. Gott and Hinchliff [7] also found, that in older adults age was seen as facilitating cooping when sex become less frequent, or stopped. It seems that for older adults in long-term relationship is normal that sex will become less possible with normal ageing and the cessation of sex is easier to cope.
As mentioning before, sexuality is affected by several aspects which plays a crucial role in sexual functioning among elderly. One of them is also social aspect which includes many factors, like gender, race, ethnicity, educational and environmental background, socioeconomic status, financial resource, and religion that affects the sexual activity in older adults [21,28]. Huffstetler [17] emphasized that internalizing negative attitudes toward sexuality and the lack of available partners are the most important social barriers in older adults. In this context DeLamater and Karraker [30] also stated that for older adults the availability of a partner seems to be an important factor for sexual functioning. Although studies [25] indicate that man population is more sexually active, Lindau et al. [24] found that the difference in overall rates between man and woman is manly explained by the relative shortage of man which is in turn due to disparity in ages between partners. In fact, men tend to be older than their spouses but also there is present higher longevity among woman which in older ages results in a shortage of man in later life period [30]. Therefore, Gott and Hinchliff [25] found that older people who are not in relationship or are widowed plays lesser importance on sex. Relationships factors are important because it is difficult to isolate sexual function out of this context, and the presence or absence of partner affects sexual desire [30]. Most of older people think about sexuality as an important component of close emotional relationship in later life and express no interest in sex outside this context (for example in the form of "one night stands") [25]. Laumann et al. [33] found in their analysis of the Global Study of Sexual Attitude and Behaviors that sexual satisfaction and relationship satisfaction are highly related in older adults, which means that for aged population sex in companionate relationship also express the quality of the relationship. The same authors [33] also found that men reported higher levels of subjective sexual wellbeing regardless of sociocultural context than did woman. Older men are less likely than older woman to state that they do not enjoy in sex [21]. Besides, in the society still persist some double standards between the genders which can be explained by the cultural myth that men have greater sexual needs. In fact, when man engage in sexual activity outside the bounds of marriage it is much more acceptable, and it is often viewed as necessary for remaining healthy, whereas women adulterers are often viewed as selfish or whorish [17]. But most older adults still think that sexuality is something that is not appropriate in adult life. In fact, older adults' may internalize the stereotype of sex in older age being wrong [20]. One Finnish study [34] showed that although many older adults have an active sex life, more than half were of the opinion that sexually active life in older age is somehow inappropriate. Also cultural experiences and cohort effects are important factor in sexual expression. The oldest individuals borne before the sexual revolution are now 65 years or more and their sexual attitude differs from the generations born before them. So called "Baby Boom" generation in the period of adolescence enjoyed the sexual expression and many of them enjoy it even today [30].
Researcher [35] found a significant correlation between sexual power among the youth, middle and older man population which means that "Casanova" in the young age remains "Casano-va" in the later period of life. Another important sociocultural aspect is the religion which has also a great impact on individual's attitude toward sexuality, especially among older adults in western societies [17]. During the middle Ages, the European church decreed that sexual intercourse was solely for the purposes of procreation. In fact, older individuals who have more conservative religious beliefs are looking at the sexual intercourse and masturbation in the postmenopausal period as something with negative connotation; because this kind of sexual activity does not include the possibility of procreation they perceive it as a sin [17].
Others social aspects can also have a great influence on the sexual activity in older people, like socioeconomic status (individuals with lower socioeconomic status are more sexually active) or ethnicity (among older adults, African Americans are more sexually active than Caucasians) [17] as well as environmental restrictions, in case of communal living environment (e.g. nursing homes), where the lack of privacy may force some residents to express their sexuality in semiprivate or public places [21].

Stereotypes about sexuality in elderly
Sexuality is an intrinsic part of human being, but evidence still suggests that in elderly this area of life is often overlooked, particularly in long-term care settings [36]. Madsen [37] argue that society is a barometer for how majority feels about a certain topic such as sexuality in later life, so the societal views can be used as a guide for where changes may be needed or should be done. We may assume that society indicates, but at the same time determines the point of view about sexuality in later life. Sexuality is still stereotypically seen as something normal, desired, acceptable and meaningful when it comes to young people, but in older sexuality is perceived as unnecessary, pointless, embarrassing and even disturbing [13,[37][38][39]. Such a stereotypical viewing arises from reflecting on the elderly as unattractive, asexual and unable to get involved into intimate and sexual relationships [7] and leads to the misconception and wrong conclusion that elderly have no such needs.

Impact of stereotypes about sexuality in elderly on a perception of elderly, their relatives and nursing staff
Stereotypes about sexuality in elderly (mentioned above) may have several effects. They may affect the perception of older people themselves but also the perception of others that coexist with the elderly in the same environment (e.g. caregivers, relatives). How the elderly in nursing homes feel about their own sexuality is similar to older adults in general: interest in sex does not necessarily diminish with admission to a nursing home but engagement in sexual behavior often does [36]. According to Villar et al. [39] a large proportion of elderly pushed the sexuality aside and do not think about it anymore. Social taboos associated with sexuality in older age predominate even because many older people are still caught between their own need for intimacy but also the need to fulfill societal expectation [36]. Today's elderly still belong to the generations that were raised up in a restrictive and repressive way, but also under the influence of religion and religious education [39]. These generations think about sex as a topic that should be hidden and shall not be spoken about, because it only makes sense in terms of procreation, otherwise it can be socially and morally inappropriate in old age. This contributes to the invisibility of sexuality in old age in general. Sexual needs of older people are often ignored and overlooked by society in general and particularly in long-term care settings so the nursing care professionals have difficulties distinguishing between appropriate and inappropriate sexual expression and behavior by elderly in nursing homes [36].
Such a stereotypical point of view has an impact on the perception and consequently on attitudes of those who live nearby elderly (e.g. relatives caring for old parents in domestic environment) or are professionally involved with elderly (e.g. nursing care professionals in institutional care units or residential care facilities). Villar et al. [39] argue that a group pressure which partly derived from elderly and partly from relatives and nursing care professionals on the other side is an important factor of inhibiting sexual interest and expression. That pressure contribute to controlling behavior of elderly -the importance of what other people think about someone's sexual behavior might cause in elderly feelings of being judged and ashamed or even guilty. Roach [9] in Mahieu [13] state that perception of nursing care professionals and the ethos in the organization where they work are the main factor influencing nursing staff' attitudes toward older adults' sexuality in institutional care settings. Roach [9] points out that nursing staff perceptions and responses to residents' sexual behavior were influenced by their own level of comfort related to sexual issues as well as organizational ethos. Furthermore, nursing staff attitudes influence vice versa their own perceptions about sexual expression of elderly and the extent to which the expression is considered to be problematic or not [36]. At this point it should be noted a reverse impact of nursing care professionals' attitudes and the organizational ethos not just on well-being and self-image of residents but also vice versa on nursing staff themselves. If nurses often feel embarrassed and helpless about resident's sexual behavior (especially when uninhibited sexual behavior occurs in elderly with dementia) it might be detrimental for their self-image and causes negative experiences among them [13]. As stated previously, nursing staff experiences are affected by their own level of comfort related to sexual issues and the organizational ethos, but this in turn has an impact on staff' emotional and behavioral responses to the resident' sexuality [36]. We could conclude that there is a complex and reciprocal interaction between experience, perception and attitudes of nursing care professionals on the one side, then organizational culture of nursing home on the other side, but also the perception of what is wright and what is considered to be wrong among residents and their relatives. All these factors should be considered when exploring the effects on sexual expression among old people living in nursing homes.

Impact of institutional environment
Due to a complex interaction of various factors (mentioned above) the institutional care settings, where elderly could live for many years, represent an important and challenging area if we want to respect a right of elderly to express their sexual needs [13,39]. Expression of sexual needs among elderly in nursing homes could be also a very sensitive subject for many nursing care professionals and family members due to a variety of ethical issues and concerns, especially when dementia residents are involved because it might easily be perceived as a behavioral problem rather than the expression of human need to love and intimacy [38]. Skoberne [7] and Ziherl [6] argues that environmental factors which could have a significant impact on sexual expression among institutionalized elderly, are sometimes much more difficult to cope and change than other factors (e.g. age-related changes or diseases). According to their experience the people's view might be so deeply embedded and persistent that changing it can be a very long process.
According to Madsen [37], the institutional environment is for the elderly in many ways very restrictive. Nursing home could be an environment which may directly or indirectly limit elderly or even makes them unable to establish and maintain intimate relationships with another person. Causes of such limiting effect are many, but at the end they all lead to lack of privacy which is essential in intimate relationship. The opportunities for institutionalized old people to express their sexual needs are determined both by architectural features and institutional policy. The most common barriers to sexual expression of elderly in nursing homes derived from facility design and how the work processes are performed (institution policy, organizational protocols, rules, guidelines, instructions etc.) The result is an organized, structured and in some way directed daily life of residents. All the facts shown in Table 2 are recognized as important elements in restricting old people rights for privacy by various authors [10,37,39,40].
It seems that the main causes which are indicating a denial of sexuality among elderly by nursing care professionals are the lack of privacy and restriction of the individual person in different ways, both pointing to negative nursing staff attitudes. Personal beliefs, embarrassment and thinking that sexual expression may potentially have a disruptive effect on life in nursing homes seemed to be reasons why sexual expression of elderly is sometimes considered unacceptable [36]. Barriers mentioned in a Table 2 could be indirect indicators of negative attitudes toward sexuality in elderly. It is not only nursing staff members who may act in a negative way toward sexual expression of elderly but also managers of the institution. They may have an even greater impact on how the sexuality of elderly is accepted because of providing working conditions in the institution. As Table 2 shows one could think about listed barriers that major responsibility for attitudes toward sexuality in elderly lies on factors which seem to be dependent just on a nursing home policy and how the working processes must be carried out. But if you think about listed barriers more accurately, we can conclude that the listed causes are, after all, a result of individual's attitudes that subsequently influence the institutional culture and policies about sexual behavior in nursing homes. From that point of view the listed factors are indirect indicators of attitudes toward discussed topic, but have a direct impact on how nursing staff deals with sexual desires and needs for intimacy of residents in nursing homes.
At this point we must also consider the aspect of residents' safety. According to Madsen [37] the reason that most current policies and procedures are restrictive about sexual expression of elderly is that of ensuring safety. This seems to be especially important when it is about to protect a cognitive or physically impaired residents which may not be able to make decisions about any sexual activities. In addition there is a possibility of sexual abuse or exploitation by • structured ways how to do stuff by self in nursing home facilities -predetermined way to do something or perform something (e.g. when and how to do a bath or a personal hygiene) • restrictive clothing (in a way to restrict an access to the body or parts of the body) • constant presence of nursing staff and attendants • supervision of daily activities and relationships of elderly (by nursing staff and attendants) • day and night checks by nursing staff • regulation requiring residents to remain indoors between specified hours (especially at evening or at night) • sharing the personal data of residents among nursing staff (data may become the subject of discussions, gossip, mocking and laughing or other ways for the inappropriate use of humor as a means of social control) • informing relatives and adapting things to their expectations to avoid problems • making decisions in consent of relatives but without resident permission or regardless of her / him wishes • using a medical model approach to care where staff assume the role of decision-maker and establish routines that facilitate working processes without disruption, but also with little or none consideration about what residents' needs about sexual expression are other resident, even partner. This is supported also by Mahieu et al. [38] who claim that principle of respecting the autonomy is most mentioned factor in assessing the permissibility for sexual behavior in institutionalized elderly persons, but only when elderly person is still capable to make decisions. If elderly suffer from mental and/or physical deterioration their need and desire for sexual fulfillment and intimacy is being denied -resident is seen only as a patient [38] in which we think that the physical needs must be fulfilled first and that only physical needs should be met. This (medical) point of view does not support a holistic approach in nursing care of elderly. It shows that nursing staff is thinking about sexuality in elderly as unimportant and useless and consequently would not promote this area of life of the elderly. Even more, caregivers think that nothing bad happens if this area remains neglected [1,11]. This avoidance is consistent with the findings of Villar et al. [39] that under the pretext of "ensuring safety" lays tendency to avoid problems regarding sexual behavior and to satisfy expectations of relatives.

Nursing care professionals' attitudes towards sexuality among institutionalized elderly
It is already clear that the sexuality among institutionalized elderly is a delicate topic from many aspects. Therefore, at the beginning we must always ask, what is our position on the topic -and therefore what is the point of view about sexuality in nursing homes among employees. In nursing homes residents and staff are in constant contact so they both develop strong interpersonal relationships which affect sexual expression in elderly [13]. In the field of exploration the nursing care professionals' attitudes towards sexuality among the elderly in nursing homes suggest a certain discrepancy between different authors. Bouman et al. [8] have found both positive and negative staff attitudes. More likely to have a positive attitude are employees with higher educational level, higher socio-economic status and many years of work experience. But on the other side, a predictive of negative attitude to late life sexuality are younger staff, less than five years experiences of working in nursing home, working with high dependent residents and also in the case of strong religious beliefs [41]. On the other hand, Madsen [37] finds no relationship between staff age, years of working experience and attitudes, although it considers that this could be expected because of similar life-stage and consequently experiencing to be peers by age. Nevertheless Mahieu et al. [13] draw attention to the potential impact of methodological approaches in research-studies with a quantitative approach show more positive attitudes and those with qualitative approach more negative attitudes. On their opinion the negative climate and the lack of privacy is typical for a nursing home environment, but in spite of this the methodological approach is the factor that need to be considered as a possible cause for discrepancy in the results. In this context Bouman et al. [41] point out the inconsistency in attitude-behavior relationship as the important phenomenon that must be kept in mind when we talk about discrepancy in results. Elias and Ryan [36] emphasize that research about sexuality in elderly is not so much focused on late life sexuality as well, but rather in sexuality and dementia because of concerns and ethical dilemma nursing staff is faced with.
Nevertheless, many authors [13,37,38] are uniform in the claim that nursing care professionals still have a rather negative attitudes toward sexual behavior of elderly in institutional care settings, especially in western cultures where ageism and stereotypes are still prevailing.
Particularly it is the case in situations where nursing staff experience difficulties in distinguishing between healthy and unhealthy sexual behavior, like in elderly with dementia [13,37]. The sexual interest of elderly might be perceived as a behavioral problem rather than an expression of basic human needs [38], so the care is focusing on preventing and solving problems emerging from unwanted and unknown sexual behavior rather than the provision of holistic care to elderly, especially in those with dementia [36].

Problem statement
Limited numbers of studies assess attitudes toward sexuality among elderly in nursing care homes [36]. Sexuality of elderly in nursing homes is determined by complex relations between several variables, pertaining to the individual, institution, social milieu and societal culture. The question of how nursing care professionals evaluate sexuality among elderly in the nursing home facilities and which underlying meaning they assign to sexuality among residents of nursing homes can have an important impact especially on institutional practices and policies related to sexual intimacy of the elderly. With the aim to assess nursing care professionals' attitudes toward sexuality of elderly in nursing homes, we performed a pilot study on a sample of Slovenian nursing homes workers. The study had two goals: i) to develop an instrument to assess nursing care workers attitudes toward sexuality among institutionalized elderly and to ii) determine how nurses that work in nursing home facilities evaluate the expression of sexuality among residents of nursing homes.
The instrument for measuring attitudes toward sexuality among institutionalized elderly scale was developed as a semantic differential scale. A semantic differential technique [42,43] is a multi-item measure used to obtain a relative direct indication of attitude [44] in measuring meaning of objects and concepts. Although a review of methodological research on semantic differential [45] show its limitations, semantic differential is a technique widely utilized in studies examining attitudes and stereotypes toward different objects and concepts, especially in relation to age [46][47][48] and questions that incorporate stronger affective component, such as the women's attitudes toward menopause [49]. Ajzen [50] notes that semantic differential has been in previous studies employed as a measure of affect toward the object and also as a measure of cognition, and concludes that "it is thus possible, by carefully selecting appropriate scales, to use the semantic differential to assess and attitude's cognitive or affective component." [50]. Since previous studies [37] show that sexual behavior of elderly in institutional care settings is connected with rather negative reactions of nursing staff and with stereotypes toward older people, we can expect a stronger affective component of nursing staff attitudes toward perceived sexuality among elderly in nursing care facilities. The differential scale technique is therefore a good approach for the development of a scale that measures evaluations and reactions of nursing care professionals toward sexuality of elderly. In the next section we present the procedure of the development of the attitudes toward sexuality among institutionalized elderly scale.

Instrument: Scale development and scale description
The attitude toward sexuality among institutionalized elderly scale development process included three stages: i) the identification of adjectives through which nursing care professionals describe and evaluate perceived expressions of intimate relations between elderly in nursing homes, ii) the formation of a list of adjectives that represent evaluations of perceived intimate relations between elderly in nursing homes, and iii) the formation of a list of bipolar sets of adjectives that describe attributes and behavioural characteristics of intimate relations between institutionalized elderly from the perspective of nursing care professionals.
The adjectives through which nursing care professionals describe and evaluate perceived expressions of intimate relations between elderly in nursing homes were identified through a focus group with students, enrolled in the second cycle bologna study programme of nursing care. In the focus group 15 students participated, the majority of them already employed and with experience in nursing practice, two of them also in nursing home facilities. Two questions were discussed with focus group members: i) how do you, as a nursing care professional, evaluate different forms of expression of intimacy and sexuality between elderly in nursing home facilities, ii) is there any discrepancy between your evaluations as a person and as a nursing care professional -if yes; why such differences in evaluations exists? Examples of evaluations of the theme that have emerged during the focus group are: "Well, it is god for their health, although sometimes disturbing for us, as health care workers", "It's embarrassing."…"It can be perceived aggressive or better determinant… but on the other hand it is their intimacy… until it is spontaneous or honest...". "It's not easy; we know that this is something ordinary, spontaneous, frequent." From responses of focus group interview 51 adjectives through which nurses evaluate perceived sexuality and intimacy of elderly in nursing home facilities were identified. From the list, synonyms and similar adjectives were excluded, resulting in a list of 31 adjectives.
In the second step the list of 31 adjectives was discussed with the second group of 21 nursing care students, enrolled in the second cycle bologna study programme of nursing care. Also the second group of students included participants with experience in nursing care practice, also in nursing home and other forms of health care facilities for older people. The discussion was directed toward the validation of identified adjectives (comparison with personal experience) and overall evaluation of the list of adjectives. In the second step a list of 26 adjectives was identified.
From the final list of 26 adjectives we formulated a list of bipolar sets of adjectives (26 items) that describe evaluations intimate relations between institutionalized elderly (older than 75 years) from the perspective of nursing care professionals. The adjectives incorporate the evaluations of behavioural characteristics of the object of evaluations (strong, frequent, intensive, spontaneous) and the attributes assigned to the object from the perspective of nursing care professionals that perceive intimate relations (tolerant, liberal, disrupting, acceptable). The instruction for respondents was developed in accordance to the Rosencranz and McNevin's [48] formulation, adapted to the object of evaluations. Each of the 30 scales was scored from 1 to 7, for example: Healthy 1-2-3-4-5-6-7 Un-healthy; Frequent 1-2-3-4-5-6-7 Seldom; Intimate 1-2-3-4-5-6-7 Public.

Sample
In the pilot study 106 nursing care professionals participated, employed in 5 different nursing homes in Slovenia. In the sample 88 % nursing care professionals were female. The majority of participants were aged between 35 and 50 years (56 %). Participants with finished at least secondary nursing education (88 %) are working in nursing homes as nurse assistants; participants that have finished at least a bachelor nursing study programmes (12 %) are working as registered nurses.

Data analysis
In the pilot study we performed the reliability and dimensional structure analysis (varimax and oblimin exploratory factor analysis) of the attitudes toward intimate relations between institutionalized elderly scale and calculated the descriptive statistics of the 26 items.

Results
We performed exploratory factor analysis (principal component) with varimax and oblimin rotation. The factor analysis produced two factors ( Table 3) Table 3), with 23 items and two-dimension structure has appropriate level of internal consistency (Chronbach's alpha=0,91). The first factor (34,8 % of explained variance) includes adjectives, such as: safe, healthy, acceptable, spontaneous, pleasant, ordinary. The second factor (11,9 % of explained variance) includes adjectives, such as: exciting, intensive, active, frequently. In accordance with basic three dimensional structure of attitudes -evaluation, potency, activity [50], confirmed also in studies utilising semantic differential scale as a measure of attitudes [45], the first factor obtained in our study incorporates mainly the evaluation dimension of attitudes structure, and the second factor incorporates the activity and the potency dimension. From a more detailed analysis of the adjectives indicating both factors, it is also evident, that the first factor incorporates adjectives that mainly describe the pleasant-unpleasant dimension of reactions toward the studied concept, and the adjectives describing the second dimension includes adjectives that indicate the arousal-activation reactions. The pleasant-unpleasant and the arousal-activation have been consistently found as dimensions describing the emotional terms or the affective component of attitudes [50]. The adjectives included in the attitudes toward intimate relations between institutionalized elderly scale represent evaluations strongly connected to affective responses toward the studied attitudinal object.

Discussion and conclusions
The pilot study of attitudes toward intimate relations between institutionalized elderly scale had two goals: i) to develop an instrument to assess nursing care professionals attitudes toward sexuality among institutionalized elderly and to ii) determine how nurses that work in nursing home facilities evaluate the expression of sexuality among residents of nursing homes. Already during the process of the scale development, especially during the focus groups with nursing care students, the beliefs, behavioral and affective reactions toward the theme (sexuality toward elderly in institutional care) were evoked. For participants of the focus group the theme was embarrassing and needed some time to feel comfortable in their expressions. The dichotomy of the question "what it is right" and "how I feel about that" was clearly expressed in participants comments: "I know, it is something ordinary, it is normal and many times for them a pleasant experience that enhance the quality of their life, but still, I do not feel relaxed, I am embarrassed when I encounter such situations or when they want to discuss about sexuality and intimacy… Probably it is so because we are talking about sexuality, the age of people involved… also the fact that people live in institutions, where thinks must be under "control" all the time." Similar notion of self-justification in avoiding problems and interactions in relation to sexual behavior can be found in Villar et al. [39]. "Having the control over the situation" is a form of similar self-justification as to "ensure safety" [39]. Self-justification is in this case needed as a mean to avoid taboos and social presssures related to them.
The factor analysis of the attitudes toward intimate relations between institutionalized elderly scale suggests that nursing staff attitudes toward sexuality and intimate relations of institutionalized elderly have a strong affective component. Exploring nursing staff attitudes towards sexuality among elderly in nursing homes suggests that this is still a taboo issue. The qualitative phase of the scale development process offers deeper understanding of the evaluations of the theme, more than the assessed evaluations. Therefore in further studies of attitudes toward elderly in institutionalized settings, a mixed method approach is advised. The attitudes toward intimate relations between institutionalized elderly scale needs further studies on its reliability and validity, as well as additional validation of the adjectives included in the scale.
Sexuality of elderly in nursing homes is a complex societal phenomenon with multiple causes arising from different groups of people for a given society coexisting with old people. In a first place it is about attitudes that elderly might have towards their own sexuality. Here we must also take into account their desires and ability to fulfill sexual needs if there are any. A second important factor are relatives with their personal views on sexual life in general what may have a great impact in determining what should be or should be not the sexual lives of their parents living in nursing home. Finally we must consider how life in the institution itself might influence the sexual expression of elderly. Although it seems that the impact on sexuality among elderly depends especially upon the policy of nursing home and work processes, it is basically always influenced by attitudes of the individual. Nursing home policy and staff attitudes seem to be in vice versa relationship. Those attitudes make positive or negative effects on the nursing homes policy about sexual expression in late life, but also a vice versa effect on individuals (nursing staff and residents in nursing homes). To break this vicious circle we have to take into account that only education is not enough. Nursing staff must get also a concrete practical experience working with the elderly. This will allow them to know, recognize and understand, without any judgment, the area of sexuality in institutionalized elderly. Willing to know, understand and accept is a starting point in implementing a more permissive attitude to the sexuality among elderly which can be subsequently resulting in practice through restructured nursing home policies and ways of addressing the elderly when it is to ensure and facilitate their need, desire and rights for close, intimate relationships. A balance between rights of elderly to fulfill their sexual needs and ensuring them safety, on the other hand is a very important and challenging aspect for restructuring nursing home policies in a way that this area of late life would be respected as it must be. This is necessarily associated with cultural and even religion characteristics of society, but also with capability of recognizing the need for more knowledge and tolerance regarding sexual expression in elderly. If we point out that sexuality is an important area of human's life, then is not difficult to recognize the importance of training from an early age in a sense of instilling tolerance and understanding sexuality in different stages of life.