What Distresses Sexual Well-Being Among Older Adults in Different Cultures? A Qualitative Study with Slovenian and Portuguese Older Adults

To analyze the perspectives of sexual unwellness (SU) of Portuguese and Slovenian older adults was the objective of this study. A qualitative research was carried out, in which these perceptions were analyzed at a cultural level. The sample of this study consisted of 136 older participants, between 65 and 96 years of age. Participants were of two different nationalities and lived in the community. Participants were interviewed, and all interviews were carried out through the process of literal transcription and subsequent content analysis. Eight key mutually exclusive themes emerged from the interviews: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex; and difficulties meeting new people. Unavailability of partner was the most important theme (17.9%) for the studied sample and specifically among Portuguese participants. Conversely, difficulties meeting new people were the least reported theme (6.8%) for the entire sample. For Slovenians traditional values were most relevant with respect to feeling sexually unwell. Older adults from two different countries reported diverse sexual experiences. Eight mutual-exclusive themes were extensively illustrated. These findings are evidence for cultural-adapted interventions and policy making in the context of older adults’ sexual well-being, particularly in terms of its relation with aging well.


Introduction
Oder adults have been stereotyped, both explicitly and implicitly, as being asexual or naturally lacking sexual desires (Liu et al., 2016). However, senior individuals are sexually active, albeit more, so among men versus women (Liu et al., 2016). Worldwide, approximately 60% of adults between 45 and 59 years old have intercourse at least once a week and at age 75, 25% still do so. Moreover, among this age group, 75% have intercourse once a month or more (Harvard Health Publishing, 2020). Another study indicated that 39.5% of older women and 67.0% of older men between 65 and 74 years old remain sexually activity (von Humboldt et al., 2020a, b). When older adults have partners, 64% of men and 68% of women are report being satisfied with their sex lives. Fewer older people without partners (18% of men and 28% of women) are pleased with their sex lives (Harvard Health Publishing, 2020). High levels of sexual activity and the absence of sexual issues are positively have been correlated with subjective well-being among older adults, regardless health, family relations or demographic factors (Carneiro et al., 2019;Ribeiro-Gonçalves et al., 2022;von Humboldt et al., 2020). Between 40 and 70 years of age, psychological well-being and the lack of psychological distress are key factors in women's overall satisfaction with their sex lives and their sexual well-being (SWB) .
Portugal and Slovenia show similar cultural aspects; they are both European and Westernized cultures, hence the context of social values and stereotypes tend to be similar, and regarding the experience of sexuality, both countries show conservative approaches. In addition, the two countries have an increasing number of older people who are isolated and with a feeble support network, Moreover, projections indicate that Portugal will have a more pronounced aging of the population until 2080 (EuroNews, 2016;von Humboldt et al., 2018von Humboldt et al., , 2022. The quality of life in old age in Portugal and Slovenia are also similar, since the unsatisfactory living conditions of this population, and the less adaptive habits can affect older adults' SWB, particularly knowing that social and community support in both contexts are still not adequate (EuroNews, 2016;Trigueirão, 2020).
Little empirical attention has been paid to SWB, with this both directly and indirectly contributing to successful aging (von Humboldt et al., 2020a, b) and satisfaction with life, quality of life, and overall psychological well-being (Traeen & Villar, 2020). This psychosocial concept pertains to sexual interest, functioning, satisfaction, healthy intimate relationships, and sexual self-esteem (Syme et al., 2015;von Humboldt et al., 2020a, b).
Moreover, research indicates that emotional and physical well-being are correlated with older people's SWB, including their general sense of happiness , b, 2015a, b, 2017von Humboldt et al., 2013avon Humboldt et al., , b, c, 2014a.
Sexual distress encompasses a variety of relevant aspects, such as biopsychosocial factors and cultural and health care contexts and has been associated with a higher sexual dissatisfaction and increased sexual avoidance (Syme et al., 2015).
Sexual distress is different from sexual dysfunction. Distress is an indicator of suffering while dysfunction pertains to difficult or painful sexual experiences (Cuenca-Barrales et al., 2019). Although physical issues in old age can have a strong impact in reducing frequency of sexual activity (Syme et al., 2015), literature concerning SU suggests that the most referred indicator is the lack of intimacy and affection, whilst the least verbalized indicator is poor sexual health (von Humboldt et al., 2020a, b). These findings corroborate previous studies wherein psychological and relational opposed to physical health factors most influence older people's sexual satisfaction (Syme et al., 2015). Older adults may be challenged with the loss or incapacity of a partner. Married older people report having more sexual activity than do their widowed or single counterparts (Liu et al., 2016). Older adults whose partners are in less than ideal health, cognitive impaired, or institutionalized report that these factors greatly interfere with their sexual performance and lessen its importance (Kumar & Sharma, 2017). Conversely, emotional intimacy can dampen the suffering associated with sexual difficulties. Older people are at higher risk for chronic illnesses, many of which (including medical treatment) can affect their SWB. Hence, the link between intimacy and sexual distress may be particularly relevant for older couples (Štulhofer et al., 2019). Indeed, single women and female patients are more likely to suffer from sexual distress (Cuenca-Barrales et al., 2019). General psychological disorders like anxiety and depression, especially when treated with medications, can affect sexual expression by lowering desire, energy, and the level motivation for engaging in sexual activity (Syme et al., 2015). Older people may also experience declines and losses in functioning which can lead to psychological distress, isolation, and even loneliness (World Health Organization (WHO), 2015;Ferreira-Valente, et al., 2019). Some longterm conditions from age 50 onward affect sexual function.
Health problems can decrease sexual desire, hinder sexual positions, increase anxiety around, for example, sexual activity triggering a heart attack, and negate overall SWB (Bouman, 2013). Financial problems seem to be linked to a poor sexual functioning. Older people with a lower socioeconomical status, especially women, are more likely to rate their sexual performance as poor (Hamilton & Julian, 2014). Attitudes and beliefs towards aging can also impact older people's sex lives. Negative stereotypical beliefs appear to be fueled by religious values and views. For example, sexual intercourse may be seen as a primarily reproductive activity, which may underline a restrictive perspective of the sexual function (Štulhofer et al., 2018). Research supports previous findings that significant life events, especially untoward changes in one's health, can have a negative impact on older adults' sex lives (Fileborn et al., 2015). Moreover, other factors, such as the biomedicalization of sexuality in old age, body changes, work difficulties, and family disputes can negatively influence sexual activity availability and enhance SU (von Humboldt et al., 2020a, b). Sexual distress is significantly correlated with the demand for professional help worldwide . There are also cultural differences in perspectives of SU in older age (von Humboldt et al., 2020a, b). Hald et al. (2019) found remarkable cultural differences in suffering as it pertains to sexual problems, with men from southern Europe (e.g., Portugal) being more prone than their Danish and Norwegian counterparts. Sexual distress can affect older adults' health (Smith et al., 2019). Older adults with poor or unsatisfactory sex lives tend to rate their health as poor and experience lower levels of well-being. Poorer sexual performance seems to negatively influence older adults' psychological well-being, happiness, and self-esteem, with sexuality being an important structuring pole for their identity and personality (Carneiro et al., 2019;Ribeiro-Gonçalves et al., 2022;von Humboldt et al., 2020). Sexual difficulties such as erectile function among men and decreased sexual desire among women (Kumar & Sharma, 2017) are negatively related to cardiovascular problems, diabetes, depression, and other illnesses (Camacho & Reyes-Ortiz, 2005). In particular, Gledhill and Schweitzer (2013) highlighted that the socially constructed nature of a sexual identity centered around sexual penetration is negatively affected by men's sexual dysfunction. Some older adults who feel too much emphasis on the functional versus relational aspects of sex, with the latter equating penetration with sexual desire, may have disappointing sexual experiences (Gewirtz-Meydan et al., 2020). In addition, medications for erectile augmentation fail to address relationship quality (Gledhill & Schweitzer, 2013). Sexual difficulties can have a negative impact on relationships and psychological wellbeing, with both being a significant source of distress in later life . Sexual difficulties have been found to negatively impact older people's psychological well-being and interpersonal relationship quality (Fileborn et al., 2015).
Particularly, when evaluating the Portuguese and Slovenian contexts, some similarities that may be influencing the sexual experience in old age, were found. Sexuality is still an intimidating topic and may reflect some prejudgment about old age in both countries (Klavs et al., 2006;Simetinger & Otorepec, 2017;von Humboldt et al., 2020avon Humboldt et al., , b, 2022. Further, aging of the population is increasing significantly in Portugal and Slovenia, in line with an existing insufficient approach to sexuality in old age; both in research and in the health contexts (von Humboldt et al., 2022;WHO, 2015). Hence, there is a current need to analyze the two contexts simultaneously and comparatively. Moreover, it is likely that the current generations of adults want to be prepared to deal with the aging process itself.
Very little is known about what makes older people feel unwell and dissatisfied with their sexual lives. These knowledge gaps also point to a need to better understand what successful sexual aging constitutes, particularly in terms of its connection with the general well-being of older adults (Štulhofer et al., 2018, 2019). Cross-cultural studies are also lacking (von Humboldt et al., 2020a, b). Accordingly, this cross-cultural study sheds light on older Portuguese and Slovenian persons' perspectives on the key factors that have had a negative influence on their SWB.

Participants
Our participants were recruited through community centers, senior's universities, and other learning centers. Contact was made initially by telephone and face-to-face contact. At this point, potential participants were made aware of the main objectives of this study and were invited to participate, and their questions were clarified. Interested participants provided contact information so that interviews could be scheduled. Inclusion criteria for this study were (1) age equal to or above 65 years; (2) understanding the purpose of and agreeing to take part in the study; (3) agreeing to a Mini Mental State Examination (MMSE) screening test; and (4) not undergoing medical and psychotherapeutic treatments for sexual problems. No monetary compensation was offered. Participants provided informed consent prior to being interviewed. Semi-structured interviews were recorded and transcribed in full, and subsequently subjected to a content analysis. Here, the aim was to analyze participants' perceptions of those who contribute to their SU. One hundred and thirty-six older adults who were, on average, 71.55 years of age took part. Nearly two-thirds (62.5%) were women, 86% were married or had a partner, 27.9% lived alone, and 31.6% were high school and/or post-secondary graduates. The majority of our participants had a family annual income equal to or less than 25.000 € and 74.3% were retired (see Table 1). Participants lived in the regions of Lisbon and Algarve. The study was accepted by the ethics committee at the William James Research Center at the ISPA-Institute. All recruitment and analytical procedures were in keeping with the ethical standards of the 1964 Helsinki Declaration for research with human subjects and its later amendments or comparable ethical standards.

Data Analysis
A brief and general reading of the interviews was first carried out by evaluators of the content of the interviews. The analysis was carried out by two experienced researchers. The analysis started with a codification process to classify data according to the nature of its content and to group this content into categories. This classification was made from the different references that the participants made to the construct or themes of the construct. A numeric code was assigned to each category so that we had a list of codes (Sampaio & Lycarião, 2018). This list of category codes was then grouped into more general topics constituting main themes. To ensure that divergences in the coding process would not influence our findings, the two researchers reviewed the entire coding list, until they reached consensus. This stepwise approach makes replicability possible (e.g., mutually exclusive and consistently applied codes). After obtaining a set of main themes, two researchers manually coded a random sample of participants with the aim of improving interpretive convergence (Saldaña, 2009). This permitted critical evaluations of the coding process and small modifications in the coding structure (see Fig. 1). Cohen's Kappa was used to assess the agreement between the researchers regarding the codifications made for each interview, within the different categories. Cohen's Kappa shows a very good reliability for both samples (kPort = 0.86; kSlov = 0.75) for the following categories: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex and difficulties to meet new people. A descriptive quantification process was also undertaken wherein averages, and percentages across categories were calculated (Bengtsson, 2016;Elo et al., 2014;Erlingsson & Brysiewicz, 2017).

Results
Sexual unwellness (SU) was found to have culturally diverse meanings among our older Portuguese and Slovenian interviewees. Eight key mutually exclusive themes emerged: unavailability of partner; traditional values; body restrictions; low self-esteem and well-being; poor social support; dissatisfaction with physical appearance; pain during sex; and difficulties meeting new people. The information shared by each participant could have added to different themes. These themes are outlined below.

Theme 1: Unavailability of Partner
The physical absence of a partner or unavailability for incapacity or illness was the most indicator of SU (n = 42). This theme was reported mainly by Portuguese participants (nPort = 36). Six Slovenian participants verbalized this theme. When illness compromises a partner's autonomy and availability, being a caregiver of that partner can become a burden and, in turn, negatively affect SWB. Teresa explains: "I help my partner in everything, but I cannot help him with sexual relations, because sexuality is individual, it is something special that belongs to each one individually" (Teresa; female, 81 years old). It is important to remember that people with dementia experience significant decrements in their cognitive and physical functioning and their ability to navigate their living environments, with these hampering the expression of intimacy and sexuality. "I think I am no longer able to express myself sexually" says Paul (male, 80 years old). Additionally, 37% of our participants had lost a partner, mainly through widowhood, and this strongly compromised the ability to have sex and their SWB. As Alfreda pointed

Theme 2: Traditional Values
Participants (n = 39) also indicated that traditional values were an obstacle to their SWB. This theme was mostly reported by Slovenian participants (nSlov = 22 versus nPort = 17). Looking back at sexuality after age 60 suggests a theme, which, in general, speaks to cultural denial such as through negating sex in older age. Nicole says: "We are used to following the idea that having a sex life is only for the youngest. And this is wrong. Older people also have this right" (Nicole; female, 66 years-old). Culture and certain traditions accompanied participants throughout life and seemed to restrict their sex lives. This theme was dominant (67%) among older women. As Susan verbalized "Sometimes I feel ashamed, or I don't want to talk about my sex life, because taking into account my culture, having sex at this age is not seen as a good thing" (Susan; female, 67 years old). Additionally, religious values were reported as negatively impacting SWB. Francisca reported that "I am focus on God, I do not think about sex anymore. It is a sin, if it is not made to procreate. I already had my five children and I am done with it" (Francisca; female, 87 years old).

Theme 3: Body Restrictions
The third most prominent theme, body restrictions (n = 37), was mostly reported by Portuguese participants (nPort = 33 versus nSlov = 4). Falls were pointed out as restrictive factor because falls contributed to physical incapacity and a lengthy recovery process. Missing at least one limb can be problematic. Jimmy told "My two legs were bad for long time, and it was always challenging to satisfy any sexual partner for two main reasons -for one, evidently, my overall physical appearance, it doesn't get simpler than that, she would just reject me from the moment she would lay their eyes on me; then, if I was lucky enough to get it on with a partner, that relationship would end rather quickly because, from a sexual standpoint, it would be too unsatisfying and need to much work to come." (Jimmy; male, 76 years-old). Additionally, falls affect mobility in old age. Gabriela emphasized "Even only going outside to take out the trash and to go to the grocery store is already painful.

Theme 4: Low Self-Esteem and Well-Being
Some participants (n = 28) indicated that low self-esteem and well-being was an obstacle to their SWB. This theme was mostly reported by Slovenian participants (nSlov = 17 versus nPort = 11). "Regardless of my problems, when I feel beautiful and feel that my presence causes a positive feeling for my partner, this makes me feel happy, and that will be expressed in my sexual activities," verbalized Emily (female, 67 years old). Physical activity seems to be a favorable factor facilitating positive bodily changes that enhance selfesteem and confidence. Physical activity allows older adults to become more active and more able to perform daily living activities, including sexual activities. "We both started going to the gym a little bit and ended up also increasing our sexual intimacy," verbalized Mia (female, 68 years old). Some participants pointed out that low self-esteem compromised their sex life. Valuing what is young, beautiful, new, to the detriment of the old, interferes with older adults' selfesteem, as their opinions about themselves may be compromised. "Babies are cute, teenagers are wonderful, adults are fantastic and older adults are the most beautiful, because we have already gone through all the stages. And sex is great" reported Diana (female, 87 years old). Other participants reported that low well-being negatively affected their SWB. "My low well-being has a big negative impact; and it is still important for me to have sex" (Natasa; female, 76 years old).

Theme 5: Poor Social Support
Some participants (n = 27) indicated that poor social support was detrimental to their SWB. This theme was mostly reported by Portuguese participants (nPort = 25 versus nSlov = 2). Older adults with less social support are more prone to depression. Filipa verbalized "One of the things

Theme 6: Dissatisfaction with Physical Appearance
Dissatisfaction with physical appearance was detrimental to the SWB of Portuguese (nPort = 23) participants per se and mostly for older women (88%). Appearance can negatively affect sexual expression. Laura reported that "It is normal that I am not as beautiful as I used to be, but even so, I would like to be more beautiful to have more confidence and not doubt myself on my sex life" (Laura; female, 77 yearsold). Although female participants seemed to report this theme more frequently, some men verbalized this theme. "Of course, I no longer have those abs, and beautiful muscles, so sometimes I'm afraid. I don't like to receive "no" as an answer and that's why I don't even ask if she wants to have a more intimate moment with me," reveals Tim (male, 67 years old). Dissatisfaction with body image can be related to increases in weight, especially in women, and lead to more dissatisfaction with one's physical appearance and a decrease in or an absence of intimate relationships.

Theme 7: Pain During Sex
The seventh most prominent theme was pain during sex, and this was pertinent to Portuguese participants alone (nPort = 22). Medical conditions and interventions may hinder one's sexual life, particularly with respect to pain during performance. Sara explained, "Due to some surgeries done during my life, due to my pregnancy, now, being 68 years old, ninety-percent of times I have sex with my husband (when I have it, because it happens very rarely), I get injuries in that region due to penetration, which can be extremely painful causing me to not be able to carry on with sex" (Sara; female, 67 years old). Due to the thinning and dryness of the vaginal walls after menopause, for some women sex becomes more painful. Cristina explained "because vaginal walls become so thin, they become more sensitive, and also, because they become so dry, they're less tolerant to friction that originates from penetration, which is not ideal whatsoever for pleasurable sex" (Cristina; female, 69 years old). Testicle pain and swelling can sometimes be caused by getting sexually aroused but not ejaculating. David affirmed "I do not like to admit but I have a huge problem ejaculating-regardless of how sexually aroused I become and how attracted I am to my partner, more often than I would like to admit, I just cannot ejaculate. Not only does that crush the ambient, but it also leaves me almost curled in a ball due to the sheer and stinging pain that it causes" (David; male, 87 years old). With menopause, women stop producing estrogen, and this can cause significant changes in their body and sexuality, such as vaginal dryness, natural lubrication decreases, which usually causes discomfort during penetration. Catherine admitted "Initially I was in pain, and I thought about stopping." (Catherine; female, 81 years old). After a long time without practicing sexual activities, re-engaging in routine sex can be painful, and for that reason, older adults stop expressing themselves sexually. "If something causes me pain, I don't want to continue doing it," says Alexia (female, 78 years old). After several years, older adults may believe that they have enjoyed their sex life and that painful intercourse will not enhance sexual satisfaction. "I can live without expressing myself sexually, so if it causes me pain, I will not practice," says Lily (female, 83 years old).

Discussion
The aim of this cross-cultural study was to respond to the knowledge gap around older adults' perceptions of factors that negatively influence their SWB. We found that older adults from different cultures perceived SU in diverse ways. The eight key themes arising from our data analysis were unavailability of partner, traditional values, body restrictions, low self-esteem and well-being, poor social support, dissatisfaction with physical appearance, pain during sex, and difficulties meeting new people. Unavailability of a partner was the most poignant indicator of SU, albeit mainly among Portuguese participants. In the Western countries, there are more women than older men who are living alone, and this disparity influences their rates of sexual activity and quality of life (Traeen et al., 2016). Often the lack of a partner is due to widowhood. Widowhood is a predictor of loneliness, with this increasing the probability of being alone by 193% (Yang, 2020). The loss of spouse also increases mortality (Liu et al., 2019), decreases satisfaction with life (Nakagawa & Hülür, 2021), and is an indicator of poorer health and quality of life (Holm et al., 2019). All such factors limit widowed older people's ability to have lived moments of intimacy and sexuality (Traeen et al., 2016). Health status also seems to greatly influence aloneness in later life (Forward et al., 2020;Ilgaz & Gözüm, 2019). Cognitive difficulties, declines in autonomy and functional capacity, and chronic diseases are key causes of an ability to seek out sexual partners (Forward et al., 2020;Khanna & Metgud, 2020). Sensory losses (e.g., hearing loss, loss of sight) can hamper relational interaction (Kumar & Sharma, 2017), particularly among those living with neurodegenerative diseases (Cott & Tierney, 2013;Hancox et al., 2019).
In addition, potential partner may need to assume the role of caregiver, with this not favoring marital relational equality and health (Liu et al., 2016). Older adults' younger family members can sometimes be opposed to them forming new relationships. There can be discomfort around outsiders disrupting a family nucleus or material heritage (Hancox et al., 2019). However, being alone can be significantly influenced by the quality and quantity of older adults' social support networks. When older adults have significant daily support, much of the caregiving that would be assigned to a partner can be carried out by a broader support network (Wu & Sheng, 2019). Traditional values were the second most prevalent indicator of SU, albeit mainly for Slovenian participants. Cultural, religious, and moral ideals contribute to passivity, resistance, and decline, and the inhibition of sexual behaviors in older age (Traeen et al., 2016). Moreover, sex continues to be seen as a privilege of the young and beautiful (Traeen et al., 2016). In this sense, there is a systematic denial of the merits of older individuals' sexual pleasures and desires, with this perhaps manifesting as a lack of interest in sexual activity in later life (Foley, 2015). Likewise, the loss of reproductive capacity after menopause may contribute to the idea that women no longer wish to engage in sexual activity, mainly due to the persistence of a model of sexuality centered around child-bearing (Traeen et al., 2016), and older men and andropause (Kumar & Sharma, 2017). Likewise, religious values often impact sexuality in older age (Liu et al., 2016). In particular, Judeo-Christian values promote the avoidance of sexuality and sexual pleasure (McFarland et al., 2010;Traeen et al., 2016). Although there is not much scientific evidence on the relationship between religiosity and the experience of sexuality in later life (McFarland et al., 2010), religious values often place a strong emphasis on sex as a reproductive act (McFarland et al., 2010;Traeen et al., 2016). All such beliefs can appropriate myths around asexuality and disinterest in older age (Liu et al., 2016). Religious beliefs can have a particular influence in situations where there is sex outside of marriage and in the practice of masturbation (Kumar & Sharma, 2017;McFarland et al., 2010). For single older people per se, there is also a negative relationship between satisfaction and sexual frequency and religiosity, particularly in older women (McFarland et al., 2010). Religious values can also influence the way in which older caregivers have more negative and restrictive attitudes about sexuality (Liu et al., 2016). Body restrictions were the third most common indicator of SU, mainly among Portuguese participants. Chronic diseases can decrease libido and provoke psychological consequences that influence various dimensions of self-perception, such as levels of self-esteem and self-concept (DeLamater & Koepsel, 2014;Hinchliff et al., 2017). For example, among older men, a lack of sexual pleasure has been linked to hypertension (DeLamater & Koepsel, 2014). Some medications, particularly those used to treat chronic cardiovascular disease, can negatively affect sexual desire and influence sexual expression among older people (Hinchliff et al., 2017). In addition, energy levels and negative moods can be influenced by chronic diseases, affect sexual function and sexual performance, and lead to decreases in positive self-regard (Rezasoltani et al., 2016). As such, adequate surveillance of chronic conditions and the maintenance of a healthy lifestyle can contribute to the prevention and reduction of sexual issues (DeLamater & Koepsel, 2014). Falls are also a major cause of immobility and loss of functionality. Functional capacity is essential for the occurrence of sexual activity in the older adults, although men and women have different risk profiles (Ek et al., 2018;Tran & Phan, 2017). In women, previous falls, living alone and instrumental dependence are associated with falls with significant consequences; in men, impaired chair stands, low systolic blood pressure, and previous falls are associated with falls of significant consequence (Ek et al., 2018). All such scenarios can potentially limit older people's sexual experiences through enhanced physical limitations and dependence, and psychological vulnerability (Porta et al., 2020). It is reasonable to infer that there is an association between sexual life and health in older age (Lindau & Gavrilova, 2010). The four most pointed indicator of SU was low self-esteem and well-being, with this resonating most among Slovenian participants. A decrease in self-esteem and self-concept influences sexual function and sexual performance (Rezasoltani et al., 2016). The sense of self-esteem is closely linked to one's sense of usefulness and purpose in life after retirement (Liu et al., 2016). Likewise, being healthy and independent, having a partner and feeling competent are generally identified as relevant precursors to positive self-concept in the older adults (Pinquart & Sörensen, 2001). Aging and the perceived loss of beauty is one of the most important threats to the self-esteem and sexual expression among older women (Kumar & Sharma, 2017), although beauty standards are also being increasingly pertinent among men (Kumar & Sharma, 2017). High levels of self-esteem can influence older adults' self-confidence, resulting in a greater relational initiative (Liu et al., 2016). Furthermore, the availability of health resources and relational support are some of the variables that are also associated with self-concept (Choi et al., 2011;Pinquart & Sörensen, 2001). In most countries, aging is deeply associated with loss, such as the loss of the support network, physical capacities, cognitive skills, and usefulness at work. This mindset contributes to negative perceptions of older people and lower selfesteem among older people themselves (Katz, 2010). Decreases in self-concept and general well-being have implications for the mood and the psychological availability of older people, and consequently, their initiative to seek and openness to new partners (Katz, 2010). On the other hand, family support and regular physical activity can enhance older people's sexual health and self-esteem (Liu et al., 2016). Poor social support was an indicator of SU in this study, mainly for Portuguese participants. Among older adults, reliable, close, and important people are generally family members who might also occupy caregiver and confidant roles; family support can be an important resource for older adults at the end of life (Porta et al., 2020). However, family relationships that are conflicting or negative often give rise to obligatory support, with this negatively affecting older people's physical and mental well-being and consequently, their sexual health and availability (Merz & Huxhold, 2010). Adult children sometimes hinder finding and/or do not support a new partner, which may create a physical and psychological divide between older adults and their children (Bøen et al., 2012;Palacios-Ceña et al., 2012). In fact, social support relationships can allow common relationships to open up the possibility to potential partners (Bøen et al., 2012;Traeen et al., 2016), and this is important because having a partner is a predictor of sexual inactivity (Palacios-Ceña et al., 2012). Furthermore, being married may help old people to feel younger and to be more health-conscious (Wong & Waite, 2015). Family issues can also influence the emotional stability of older adults such as through enhanced anxiety, and this can affect sexual expression and function (Dang et al., 2020;Xu et al., 2017). Furthermore, as the theory of socioemotional selectivity suggests, older people invest more time and energy into the quality rather than the quantity of supportive relationships (Dai et al., 2016). As such older people's closest support resources (e.g., family) most influence their emotional states (Dang et al., 2020). Dissatisfaction with physical appearance was a frequent indicator of SU, mainly among Portuguese participants. Sexual activity in later life is closely associated with body image and sexual selfconcept, particularly when it comes to initiating sexual behaviors (Liu et al., 2016). The way people experience their selfconcept differs by sex. For example, while men's self-concept is mainly associated with career development, women's revolves more around social relationships (Jankowski et al, 2014;Pinquart & Sörensen, 2001). Women in general seem to be less satisfied than men with their bodies, particularly with regard to sexuality; however, older women seem to be less vulnerable and dissatisfied than younger women (Homan & Boyatzis, 2009;Traeen et al., 2016). Older people's self-concept influences how they perceive themselves and their sense of selfefficacy and self-sufficiency, and consequently, their propensity for specific sexual activities (Liu et al., 2016). Sexual satisfaction in later life has also been associated with positive body image and perceived attractiveness (Woertman & van den Brink, 2012), with body hypervigilance and shame perhaps diverting attention away from sexual pleasure and enhancing sexual difficulties (Claudat & Warren, 2014). Our youthoriented and consumption-oriented culture marginalized older adults. Modern images of older bodies are limited to problematic bodies whereas younger bodies are associated with trendy lifestyles, appearances, and behaviors (Oberg & Tornstam, 2001). Nutrition is also essential. Weight loss among older adults can lead to cachexia and energy deficits which negatively impact their sex lives (Nieuwenhuizen et al., 2010;Oberg & Tornstam, 2001). Recent research has increasingly valued the practice of physical exercise, anti-aging elixirs, and sexual stigma (Foley, 2015). For example, older people, who engage in physical activity feel more confident about their image, are more sexually active and report fewer sexual issues (Smith et al., 2019). Accordingly, physical activity is likely to have a positive impact on older people's body image, self-concept, and sexual satisfaction (Smith et al., 2019). Pain during sex was the second least indicator of SU, particular for Portuguese participants. Discomfort during sexual intercourse is a common problem in older women, especially in postmenopausal women, often decreasing sexual initiative (Ambler et al., 2012). Loss of sexual interest can result from a conditional expectation of significant discomfort during intercourse, but high anxiety can also cause sexual pain by decreasing blood flow to the vaginal area (Ambler et al., 2012;Laumann & Waite, 2008). However, using lubricants can lessen sexual pain during penetration (Kumar & Sharma, 2017). Small doses of estrogen vaginal cream can improve lubrication and decrease pain during intercourse; however, responses to estrogen often vary (Ambler et al., 2012;Sinković & Towler, 2018). Likewise, therapies to prevent vaginal pain among menopausal women can delay or prevention 1 3 subsequent declines in sexual desire. The strong associations between psychological status, health in general, social factors, and sexual function highlight a need for primary health care practitioners to explore with older women how such factors concomitantly affect sexual dysfunction (Ambler et al., 2012;Sinković & Towler, 2018). Research suggests that yoga can be an effective pain reliever (Teut et al., 2016). However, chronic pain is often a problem that more holistically influences an individual's general well-being, requiring a more general approach and is particularly important in preventing the influence of pain on sexual health (Teut et al., 2016). Discomfort with sex was a significant correlate for searching professional support for both older women and men Married Portuguese women with higher education are more likely to seek professional help. Among Portuguese men, level of education and religiosity play a role. It may be that older Portuguese women are more likely to disclose a need for professional help because a large number of doctors are trained in sexual medicine in Portugal . Difficulties meeting new people were the least common indicator of SU, and this was mentioned mainly by Portuguese participants. Marked behavioral inhibition can be a warning sign of emotional distress among older adults, including sadness, depression, and anxiety (Freak-Poli et al., 2017). In this sense, it is essential to promote autonomy and to respect older adults' decisions to engage in new affective and sexual relationships. Health professionals and family members need to be aware of the difficulties that older adults feel when it comes to expressing their sexuality (Freak-Poli et al., 2017). Older adults have difficulties finding new love relationships when they lose partners, with long-standing myths about "old" as asexual further hindering rather than helping them (Kumar & Sharma, 2017). Creating new relationships is closely associated with social networks and support, with adult children, friends, neighbors, and broader ties to a community being fundamental to older adults' well-being and motivation (Jin et al., 2020). Other studies report negative associations between intergenerational social support and filial expectations, and older adults' depressive symptoms among older adults which, in turn, dampen expressions of sexuality (Ding et al., 2020). Moreover, the perception among older adults that love and a new marriage is unacceptable in later life has been associated with less social activity (Kim et al., 2020). On the other hand, online relationships are becoming increasingly common in later life. Approximately one-third of older men and one-sixth of older women indicate that they have used the internet for sexual and amorous purposes . The use of the internet for sexual/ relational purposes was higher among partnered people who were satisfied with their current level of sexual activity . Online relationships appear to be intimate and long-lasting; for some older people, cybersex is a routine practice . Still, older Portuguese men are less likely to view pornography, purchase of sexual products, and search for partners with commitment objectives over the internet . The findings of this study indicate that specific themes that contribute to SU on both countries. Unavailability of partner was the most important theme (17.9%), especially for Portuguese participants. Conversely, difficulties meeting new people were the least reported theme (6.8%) for Portuguese and Slovenian participants. Slovenian participants reported that traditional values were most relevant to their SU.
It must be noted that these two countries show some socio-cultural similarities. Portugal and Slovenia are ranked among the safest countries in the world, which can contribute to a better quality of life, comfort and safety among older adults, even with frailty. In addition, the two countries show a mild climate, which may be associated with healthier lifestyles, in particular, sun exposure, and a Mediterranean diet (Institute for Economics and Peace (IEP), 2021; Veiga, 2019). Portugal and Slovenia also share common psychosocial factors that may have influenced current traditional values in these countries, particularly those relating to the experience of sexuality, such as the existence, in both countries, of dictatorial periods in the first half of the twentieth century; resulting in general repression, as well as sexual repression (Mazat, 2011;Veiga, 2019).
This study encompasses a number of limitations. The sample was not as ethnically diverse as we had hoped. We lack knowledge of SU perspectives among older people born outside of Slovenia and Portugal. Qualitative studies also tend to be subject to the researcher's prejudice (e.g., incidence of personal values), although researchers are not necessarily fully conscious of this (Goll et al., 2015). As such, researchers with a broad range of theoretical-practical knowledge are more likely to engage in richer and more objective analyses (Goll et al., 2015). In addition, although the older people in this study consented to being interviewed, their contributions may have been limited by their physical or intellectual autonomy (Goll et al., 2015;Kuh et al., 2014a;WHO, 2015). Furthermore, it is important to consider that the comparisons made between the data found in the two countries were not representative, and the results should not be generalized.
On the other hand, in qualitative studies with older adults, difficulties tend to occur in the focus and exploration of the topic addressed, often due to the long trajectory of life and lived experiences. Older adults tend to disperse from the central theme of the interview to parallel themes, and this deviation can create noise when analyzing the data (Kuh et al., 2014a, b;Monteiro et al., 2017;Phoenix, 2018). In semi-structured interviews, older adults tend to refer and feel tired and bored, which can influence the resources of attention and the quality of the information transmitted (Elder et al., 2015;Hinchliff et al., 2017). The quality of information being transmitted might also decline when interviews require abstract or demanding thinking (Monteiro et al., 2017;WHO, 2015;Zibad et al., 2017). Our study also has several strengths. The sample was diverse with respect to certain sociodemographic characteristics such as income. Many participants had also experienced significant agerelated losses, including sexual expression. In these respects, the topic of sexuality was approached within a safe context. Seeking the perspectives of older people from two different countries allowed for more robust or culturally different conclusions to be drawn about the SWB. This study contributes to a better understanding of essential and littleexplored aspects of sexual health that can inform clinical prevention and intervention work. Likewise, this study offers empirical substance with which to structure sexual health interventions, mainly plans and action programs for sexual psychoeducation in different cultural contexts. This qualitative study on the SWB also allows older adults to reflect on aspects of their sexual health that are often overlooked due to long-standing myths about sexuality in later life. It should also be noted that future interventions targeting older groups will need to address individual beliefs, as well as structural and social factors (i.e., transportation issues, social networks) to optimize participation. The results of this qualitative study indicate that it is necessary that older participants understand the need for and the importance of a community-based qualitative study, which may contribute significantly to understanding SWB and sexual health. An approach that explores the indicators that can harm or improve SWB is essential to spread knowledge and promote public dialogue that can challenge existing stereotypes and myths that render sexual activity and wellness as matters of importance for younger generations. Studies that promote older people's perspectives about issues of sexuality play a very important social role in changing policies. This study is part of the international body of research that, as stated by the World Health Organization and the World Association for Sexual Health, contribute to the monitoring and evaluation of the sexual health of the older adults. Furthermore, this article is part of the body of research that contributed to changes in national policies, namely with the establishment of the national sexual health day which was unanimously approved in the Portuguese parliament on June 9th of this year (SPSC, 2021). In addition to affecting social policy change, we need to think about the clinical consequences of SU and preferably much earlier in the life course (Traeen & Villar, 2020). Research about and the applicability of sexual health in later life has to be elaborated upon from a preventive rather than a reactive perspective.