DOI: 10.1111/ggi.

13648

ORIGINAL ARTICLE
EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH

Sexual intimacy in later life: From the perspectives of older

couples in Malaysia
Halimatus S Minhat,1 Hazwan Mat Din,1 Tengku A Hamid1 and Siti S Hassan Nudin2
1 Aim: To identify the determinants of sexual intimacy among married older people in
Malaysian Research Institute on
Ageing, Universiti Putra Malaysia,
Serdang, Malaysia
2
Institute for Behavioral Research,
Kuala Lumpur, Malaysia
Correspondence
Associate Professor Halimatus
Sakdiah Minhat MD PhD, Medical
Gerontology Laboratory, Malaysian
Research Institute on Ageing,
Universiti Putra Malaysia, 43400
Serdang, Selangor, Malaysia.
Email: halimatus@upm.edu.my
Received: 4 August 2016
Accepted: 3 February 2019
Malaysia.
Methods: A cross-sectional study was carried out among 1294 married Malaysian older
couples who were randomly selected from all 14 states in Malaysia. The data were collected
by trained enumerators using a set of validated questionnaires consisting of eight sections,
namely sociodemographic characteristics, chronic diseases, perceived health status, life satis-
faction, body mass index, disability status (World Health Organization Disability Assessment
Schedule), social support (Lubben Social Network Scale) and sexual intimacy.
Results: Having good social support (AOR 0.57, 95% CI 0.45–0.74) from family and friends
were protective determinants against poor sexual intimacy in later life. Meanwhile, those who
were aged 70–79 years (AOR 1.81, 95% CI 1.35–2.42), aged >80 years (AOR 35.49, 95% CI
4.80–262.18), women (AOR 1.47, 95% CI 1.13–1.90), non-Malay (AOR 1.93, 95% CI
1.50–2.48), received only informal education (AOR 1.81, 95% CI 1.35–2.42), had gastritis
(AOR 2.62, 95% CI 1.58–4.34), had a stroke (AOR 3.83, 95% CI 1.04–14.12), perceived their
current health status was satisfactory (AOR 1.52, 95% CI 1.15–2.00) and disabled based on
the World Health Organization Disability Assessment Schedule (AOR 3.14, 95% CI
1.34–7.36) were at risk of poor sexual intimacy.
Conclusions: The majority of older Malaysian couples were having poor sexual intimacy
despite being still married and sleeping with their partners, reflecting the presence of underly-
ing barriers towards sexual intimacy in later life among older Malaysians. Geriatr Gerontol
Int 2019; ••: ••–••.

Keywords: couple, elderly, Malaysia, sexual intimacy.

Introduction A sexual relationship can bring love, intimacy and closeness

Malaysia is experiencing a rapid aging process, as a result of lon-
gevity associated with better health and a reduced fertility rate. By
2030, >15% of the population will be those aged ≥60 years. The
aging population in Malaysia is not only evident by the increase in
the percentage of older persons, but also the median age and old-
age dependency ratio.
The demographics transition creates a greater need to better
understand the issues, challenges and complex needs of older per-
sons, which include sexual activity and its impact on their quality
of life. Studies exploring sexual intimacy in later life have been
very limited, especially among Asian countries, including Malay-
sia, which reflects the influences of sociocultural aspects in shap-
ing the perceptions, beliefs and behaviors of the community. It is
frequently misunderstood and stigmatized, particularly among
older adults. Despite its positive impact on life satisfaction and
quality of life, many people, young and old alike, are astounded by
the idea of people remaining sexually active in their 60s and
beyond.1
The need for intimacy is ageless. Intimacy refers to a close feel-
ing shared between two people, which can be in the form of emo-
tions, social relationship and physical intimacy, such as touching,
cuddling and also sexual activity. Meanwhile, sexuality is a com-
plex and multi-dimensional concept covering the desire for sex,
the sexual act, and values and beliefs about sex.2 It involves the
whole experience of a person’s sense of self and includes a per-
son’s ability to form relationships with others, feelings about
themselves and the impacts of the physiological changes of aging
on their sexual functioning.3
that can further improve older people’s general well-being.4 Sex-
ual contact also correlates to better health, higher relationship sat-
isfaction and easier stress management.5 However, the declining
intention to have sex in later life is not only restrained by beliefs
that older adults no longer look physically attractive and thus do
not have sexual needs, and, if they do have any, they would need
to suppress them,6 and the loss of their partner, but also the sex-
ual myths associated with the older population. It is frequently
assumed that older persons lose their sexual desires or that they
are physically unable to perform.1 According to McNicoll, if an
older person is physically able and has a partner, sexual activity
and satisfaction with sex can persist well into the 90s.7 Many older
persons express sexual desire, but might fear their interest is
undignified and disgraceful. Sexuality is considered as the prov-
ince of youth, and many sexual myths and stereotypes work
against older people, and challenge whether the expression of sex-
uality in old age is appropriate.8
For some reason, many people believe sex belongs to young
people and most older adults are not interested in or able to have
enjoyable sex. However, according to a report by Brecher, the
majority of older adults are interested in sex, and lead active sex
lives and enjoy sexual activity.9 The report also emphasized the
inverse association between sexual activity and age, but more than
half of the female and male older adults were reported to be sexu-
ally active after the age of 70 years (65% and 79%, respectively).
The other common sexual myth is older women are even less
interested in sex than older men. The disparity between sexual
activity with a partner found in older men versus that in older
women is likely not mainly due to any difference in sex drive, but
rather to the fact that women typically outlive men.10,11

© 2019 Japan Geriatrics Society | 1

 HS Minhat et al.

Table 1 Characteristics of respondents Table 1 Continued

Factors n % Factors n %
Age (years) Disability status (WHODAS)
<70 years 931 71.9 Normal 1239 95.7
70–79 years 320 24.7 Disabled 55 4.3
≥80 years 43 3.3 Social support
Sex Poor 544 42.0
Male 801 61.9 Good 750 58.0
Female 493 38.1 Still sleeping with partner
Ethnicity Yes 1150 88.9
Malay 754 58.3 No 144 11.1
Non-Malay 540 41.7 Still capable in having sex
Educational level Yes 538 41.6
Formal 946 73.1 No 756 58.4
Informal 348 26.9 Sexual intimacy
Hypertension Good 533 41.2
No 751 58.0 Poor 761 58.8
Yes 543 42.0 Total n = 1294. WHODAS, World Health Organization Disability
Diabetes mellitus Assessment Schedule.
No 1050 81.1
Additionally, older women tend not to remarry, especially to
Yes 244 18.9
younger men, after the death of their spouse, which leads to older
Heart disease
men generally still having sexual partners, whereas most older
No 1182 91.3
Yes 112 8.7 widowed women remain single.
Cancer Unfortunately, sexuality or the problems related to sexual issues
No 1285 99.3 faced by older people are also receiving very little attention in any
Yes 9 0.7 national framework involving older people. This gap in government
Asthma policy mirrors the general perception and prejudices of an “asexual”
No 1153 89.1 old age, of sex in older people being disgusting or simply funny.12
Yes 141 10.9 The promotion of sexual intimacy and activity in later life should
Gastritis include changing people’s attitudes towards sex, and creating aware-
No 1176 90.9 ness on the benefits and positive impacts in later life. Thus, the
Yes 118 9.1 main objective of the present study was to explore sexual intimacy
Chronic kidney disease in later life among Malaysian older couples.
No 1276 98.6
Yes 18 1.4 Methods
Chronic arthritis
No 806 62.3 A cross-sectional study was carried out among 1294 Malaysian
Yes 488 37.7 older adults who were randomly selected from all states in Malay-
Stroke sia, from January 2007 until December 2008. The eligibility cri-
No 1275 98.5 teria for selected respondents were Malaysian older adults aged
Yes 19 1.5 ≥60 years, currently married, capable of completing the question-
Incontinence naire orally, living in the community and ambulatory. Those who
No 1278 98.8 were bedridden, lived in an institution and had severe symptoms
Yes 16 1.2 of dementia were excluded. The data were collected by trained
Constipation enumerators using a set of validated questionnaires consisting of
No 1267 97.9 eight sections, namely sociodemographic characteristics, presence
Yes 27 2.1 of chronic diseases, perceived health status (good/satisfactory/
Hearing problem poor), life satisfaction (satisfactory/unsatisfactory), body mass
No 1176 90.9 index, disability status (normal/disabled), social support (poor/
Yes 118 9.1 good) and sexual intimacy (poor/good).
Visual problem Chronic diseases were measured based on the presence of com-
No 944 73.0 mon diseases among older adults, such as hypertension, diabetes,
Yes 350 27.0 arthritis and so on. Body mass index was categorized into under-
Perceived health status weight, normal and overweight. The measurement scales involved
Good 708 54.7 ranged from 4- to 6-point Likert scales. Disability was measured
Satisfactory 409 31.6 using the WHO Disability Assessment Schedule, which is a generic
Poor 177 13.7 assessment instrument for health and disability that has been used
Life satisfaction across all diseases, including mental, neurological and addictive dis-
Satisfactory 1192 92.1 orders. Meanwhile, social support was measured using the short
Unsatisfactory 102 7.9 six-item Lubben Social Network Scale. It is a self-report measure of
Body mass index social engagement including family and friends. As for the sexual
Underweight 85 6.6 intimacy, respondents were asked if they still sleeping and capable
Normal 409 31.6 of having sex with partners. For the purpose of the analysis, sexual
Overweight 800 61.8 intimacy was categorized into "poor" and "good", with "good"
implying those who answered "yes" to the two items.

2 | © 2019 Japan Geriatrics Society

 Sexual intimacy in later life

Table 2 Associated factors of poor sexual intimacy without Table 2 Continued

adjustment for other factors
Factors Simple logistics regression
Factors Simple logistics regression
B OR† (95% CI) P
†
B OR (95% CI) P Disability status (WHODAS)
Age (years) Normal 0 1
<70 years 0 1 Disabled 1.62 5.06 (2.27–11.27) <0.001
70–79 years 0.64 1.91 (1.50–2.49) <0.001 Social support
≥80 years 3.59 36.36 (4.98–265.29) <0.001 Poor 0 1
Gender Good −0.66 0.52 (0.41–0.65) <0.001
Male 0 1 Total n = 1294. WHODAS, World Health Organization Disability
Female 0.37 1.45 (1.15–1.83) 0.002 Assessment Schedule. †Crude odds ratio.
Ethnicity
Malay 0 1 Statistical analysis
Non-Malay 0.79 2.20 (1.74–2.77) <0.001
Educational level For each variable, participants were grouped into categories and
Formal 0 1 all subsequent analysis was undertaken on this specific group of
Informal 0.91 2.48 (1.89–3.25) <0.001 participants. Multiple logistic regression was used to identify the
Hypertension predicting factors of sexual intimacy, using SPSS version 22 (IBM
No 0 1 Corporation, Chicago, IL, USA). Data were presented as adjusted
Yes 1.21 1.21 (0.97–1.52) 0.093 odds ratios (AOR) of the likelihood of the specified outcome (sex-
Diabetes mellitus ual intimacy) across correlates. Probability values and 95% confi-
No 0 1 dence intervals for each adjusted OR are presented. AOR >1
Yes 0.18 1.20 (0.90–1.59) 0.220 indicate an increased likelihood of having poor sexual intimacy,
Heart disease whereas OR <1 represent a decreased likelihood of having poor
No sexual intimacy. The significance level was set at 0.05.
Yes 0.01 1.01 (0.68–1.49) 0.979
Cancer Results
No 0 1
Yes 1.73 5.65 (0.71–45.32) 0.103 The characteristics of the respondents involved in the present
Asthma study are shown in Table 1. The majority of the older were youn-
No 0 1 ger, aged <70 years (71.9%), Malay (58.3%), received formal edu-
Yes 0.49 1.62 (1.12–2.36) 0.011 cation (73.1%), satisfied with their current lifestyle (92.1%),
Gastritis overweight (61.8%), had no disability (95.7%), received good
No 0 1 social support from family members and friends (58.0%), and
Yes 1.21 3.35 (2.01–5.510 <0.001 were still sleeping with a partner (88.9%), but incapable of having
Chronic kidney disease sex (58.4%). The proportions of male and female respondents
No 0 1 were 61.9% and 38.1%, respectively. Most of them perceived they
Yes 0.10 1.10 (0.42–2.86) 0.842 had good health status (54.7%), with hypertension as the com-
Chronic arthritis monest chronic illness (42.0%).
No 0 1 Tables 2 and 3 show the factors associated with sexual inti-
Yes 0.36 1.43 (1.13–1.80) 0.002 macy among the older adults using simple and multiple logistic
Stroke regression analyses. At simple logistics regression, without adjust-
No 0 1 ment to other variables, several variables were found to be signifi-
Yes 1.33 3.79 (1.10–13.09) 0.035 cant, including age, sex, ethnicity, educational level, asthma,
Incontinence gastritis, arthritis, stroke, hearing problem, perceived health status,
No 0 1 body mass index, disability and social support (Table 2). All these
Yes −0.36 0.70 (0.26–1.87) 0.474 variables were then included at multiple logistics regression with
Constipation additional variables, with P < 0.25 and being biologically signifi-
No 0 1 cant. The model variable selection was carried out using the for-
Yes 0.52 1.68 (0.73–3.87) 0.222 ward selection method, which showed a highly significant model
Hearing problem (χ2[d.f.] = 202.92 [11], P < 0.001). The model showed no multi-
No 0 1 collinearity and interaction between the variables. The Hosmer–
Yes 0.47 1.60 (1.06–2.40) 0.024 Lemeshow test showed a non-significant P-value. The model
Visual problem showed that age, sex, ethnicity, educational level, gastritis, stroke,
No 0 1 perceived health status, disability and social support were signifi-
Yes 0.20 1.22 (0.95–1.57) 0.122 cant variables in the model. Respondents who were aged
Perceived health status 70–79 years (AOR 1.81, 95% CI 1.35–2.42), aged >80 years (AOR
Good 0 1 35.49, 95% CI 4.80–262.18), women (AOR 1.47, 95% CI
Satisfactory 0.61 1.84 (1.43–2.78) <0.001 1.13–1.90), non-Malay (AOR 1.93, 95% CI 1.50–2.48), had infor-
Poor 0.55 1.73 (1.23–2.44) 0.002 mal education (AOR 1.81, 95% CI 1.35–2.42), had gastritis (AOR
Life satisfaction 2.62, 95% CI 1.58–4.34), had a stroke (AOR 3.83, 95% CI
Satisfactory 0 1 1.04–14.12), had satisfactory perceived health status (AOR 1.52,
Unsatisfactory 0.18 1.20 (0.79–1.82) 0.401 95% CI 1.15–2.00) and were disabled based on the World Health
Body mass index Organization Disability Assessment Schedule (AOR 3.14, 95% CI
Underweight 0 1 1.34º7.36) were more likely to have poor sexual intimacy
Normal −0.35 0.70 (0.43–1.16) 0.164 (Table 3). In contrast, respondents who received good social sup-
Overweight −0.48 0.62 (0.39–1.00) 0.050 port (AOR 0.57, 95% CI 0.45, 0.74) were less likely to have poor
sexual intimacy (Table 3).

© 2019 Japan Geriatrics Society | 3

 HS Minhat et al.

Table 3 Determinants of poor sexual intimacy with adjustment and integral to a quality relationship.18 Unfortunately, many of
of covariates the risks of sex also remain relevant in later years, as we have seen
with rising rates of sexually transmitted infections among older
Factors Multiple logistics regression adult populations.19 This is due to issues, such as poor sexual
B OR† (95% CI) P education for older adults about the importance of protection
postmenopause and their reported lack of self-efficacy in using
Age (years) sexual protection, including condom use and negotiation skills.17
<70 years 0 1 In view of the role of sexual intimacy in maintaining the
70–79 years 0.59 1.81 (1.35–2.42) <0.001 well-being of older people, the sexual taboos in later life should be
≥80 years 2.57 35.49 (4.80–262.18) <0.001 broken by delivering adequate education and awareness on the
Sex benefits and protection methods.
Male 0 1 The results of the present study also showed that good social
Female 0.38 1.47 (1.13–1.90) 0.004 support was a protective factor against poor sexual intimacy in
Ethnicity later life. As expected, extreme age of ≥80 years, having a stroke
Malay 0 1 and being disabled were the strongest predictors towards poor
Non-Malay 0.66 1.93 (1.50–2.48) <0.001 sexual intimacy among Malaysian older couples. Social support
Educational level would include the community and younger people’s perception,
Formal 0 1 including family members, about having sex in older age. Sexuality
Informal 0.39 1.48 (1.09–2.01) 0.012 in older age is often overlooked by healthcare professionals and
Gastritis even society, who imagine older people to be asexual beings.
No 0 1 Although old age is considered to be an age with many limitations,
Yes 0.96 2.62 (1.58, 4.34) <0.001 this phase can be as productive as any other phase regarding the
Stroke experience of love and sexuality. Nevertheless, aging can also
No 0 1 cause restrictions and minimize the autonomy of older persons in
Yes 1.34 3.83 (1.04–14.12) 0.044 their experience to enjoy sexuality and intimacy, thereby maintain-
Perceived current health status ing the stereotypes and myths about sexual intimacy among older
Good 0 1 adults.20
Satisfactory 0.42 1.52 (1.15–2.00) 0.003 There have been very limited studies exploring sexual interest
Poor 0.13 1.14 (0.78–1.67) 0.489 and activities among the older population. Research tends to focus
Disability (WHODAS) on the problems faced by older adults that lead to a decrease in
Normal 0 1 sexual interest and function. One of the problems is health prob-
Disabled 1.14 3.14 (1.34–7.36) 0.008 lems that lead to reprioritizing the value placed on sex. Poor phys-
Social support ical health (as self-reported) is associated with decreased interest
Poor 0 1 in sex (odds ratio 1.6 women and 2.2 men).14,21 Psychological
Good −0.56 0.57 (0.45–0.74) <0.001 problems, such as depression and its treatment, are also associated
†
Total n = 1294. Adjusted odds ratio. WHODAS, World Health Orga- with poor sexual function,22 but might be less well recognized and
nization Disability Assessment Schedule. less appropriately treated among older adults.23 Apart from that,
sexual dysfunction among older adults is also an important prob-
lem.12 Meanwhile, a study involving working-aged men and
Discussion women reported that the respondents with abundant social sup-
port considered sex life important, were satisfied with it and found
Sex, physical intimacy and emotional intimacy are lifelong needs.7 it easy to talk about their sex life more often than those with less
It can be a powerful emotional experience apart from a great tool social support.24 The support received was from their spouse or
to protect and improve health. With good understanding and an partners and friends, and was particularly significant among
open mind, every person can continue to enjoy a physically and female respondents.24 Therefore exploring the motivating factors
emotionally fulfilling sex life, regardless of age. Although sexuality for sexual intimacy is beneficial in order to understand the sexual
remains an important component of emotional and physical inti- needs of older adults in addition to understanding the problems
macy that most men and women desire to experience throughout faced by them.
their lives, it is, unfortunately, a topic many healthcare profes- The findings of the present study reflect the presence of
sionals have difficulty raising with their patients.13 underlying barriers leading to poor sexual intimacy among older
The present study showed that the majority of older adults couples, despite still being married, sleeping with their partners
involved in this study had poor sexual intimacy (incapable on and almost half still being capable of having sex. This barrier
having sex), despite still sleeping with their life partner. Although could be related to the stereotypes and myths, and also the nega-
the available research consistently suggests that increasing age is tive perceptions of the community, particularly the younger popu-
associated with a decreased interest in sex, the research also sug- lation, about having and talking about sex in later life.
gests that many older people enjoy an active sex life.14 A postal Considering the possible desire to have sex among older persons
survey with a high response rate (73%) among Swedish men and the benefits obtained from sexual activity, promoting sexual
aged 50–80 years showed that older respondents had less interest health not only involves creating awareness and instilling knowl-
in sex, with 98% of those aged 50–59 years giving it at least edge among older persons, but also includes eliminating myths
“some importance” compared with 72% of those aged and stereotype about sex in later life among the younger
70–80 years.15 Similarly, another study of the quality of life population.
among Italians found significantly less interest in sex among the
older participants, with all 38 centenarians having lost interest in
sex.16 However, a large study using face-to-face interviews of a
national probability sample of 3005 adults in the USA (response Acknowledgement
rate 75%) showed that although interest in sex was lower in
older age groups, 59% of those aged 75–85 years still attributed This study was supported by the Malaysian Research Institute on
some importance to sex.14 Aging (MyAging) and the Institute on Health Behavioral Research,
According to Syme, sexual health is an important part of well- Ministry of Health Malaysia, and was funded by the Ministry of
being in later life.17 It is an important aspect of successful aging Health Malaysia.

4 | © 2019 Japan Geriatrics Society

 Sexual intimacy in later life
Disclosure statement
The authors declare no conflict of interest.
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How to cite this article: Minhat HS, Mat Din H,
Hamid TA, Hassan Nudin SS. Sexual intimacy in later life:
From the perspectives of older couples in Malaysia. Geriatr.
Gerontol. Int. 2019;1–5. https://doi.org/10.1111/ggi.13648
| 5