Introduction
Sexual health in retired elderly men
Aging is a biological phenomenon and process that gradually limits an individual’s physical, mental, and social functions [1]. It encompasses a set of undesirable functional and structural changes that reduce an individual’s psychological and social health and adaptation [2]. The aging process is characterized by a gradual decline in the function of all body systems; however, the belief that aging is always accompanied by significant physical and intellectual deficits is merely a myth. Many older individuals retain their cognitive and physical abilities to a considerable extent. Despite evidence that many older people remain sexually active, the stereotypical notion of asexuality in the elderly persists [4].
The incidence of erectile dysfunction increases with age; however, this problem does not occur in all older men. Factors such as the presence of a sexual partner, a history of regular sexual activity in the past, and the absence of endocrine, neurological, and vascular diseases are associated with higher sexual potency in old age [3]. Epidemiological studies have shown that erectile and ejaculation problems affect approximately 50% of men aged 55 and older [12]. In 20-50% of men with erectile dysfunction, a biological cause is identified. In men over 50 years of age, the likelihood of biological causes increases and in men over 60 years of age, biological causes are the most common reason for erectile dysfunction.
The Iranian elderly population is expected to reach about 30% of the total population by 2051 [23]. Gilan province is the oldest province in the country, and the latest statistics indicate that individuals aged 60 and above comprise 13.2% of the total population of the province [24]. Therefore, health service providers in the province need to pay attention to the psychological, family, and social challenges faced by the elderly. Understanding the sexual health status of these individuals can lead to more favorable health policies regarding health education, treatment, and screening approaches, and can serve as a basis for future research. The main aim of this study was to investigate the sexual health of retired elderly men.

Methods 
This cross-sectional analytical study included 369 men aged 60 and above who were covered by retirement centers in Rasht in 2019. Based on the results of the study by Zarei et al. [25], with a confidence level of 95% and considering a margin of error of 5%, the sample size was determined to be 369 individuals according to the following sampling formula. 
The demographic questionnaire included information on age, place of residence, education level of the subjects and their spouses, occupation of the subjects and their spouses, number of children, family income, age difference between the couple, length of married life, specific physical and medical illnesses and use of specific medications.

Male sexual health questionnaire
This self-report questionnaire was designed by Rosen et al. in 2004. It consists of 25 items and measures dimensions related to sexual function and satisfaction in older men. This questionnaire is a suitable tool for assessing sexual health in men, encompassing three dimensions: erection (items 1 to 3, score range: 0 to 15), ejaculation (items 5 to 11, score range: 1 to 35), and sexual satisfaction (items 13 to 18, score range: 6 to 30). Additionally, it is used to measure discomfort due to erection (item 4, score range: 1 to 5), discomfort due to ejaculation (item 12, score range: 1 to 5), and the number of times sexual intercourse occurred during the month, the timing of the last sexual intercourse, and the reasons for not engaging in it (item 19). Respondents were scored on a Likert scale, with higher scores indicating better sexual function [26]. The validity and reliability of this questionnaire were examined in a study conducted by Fakhri et al. in 2011-12 on 388 men aged 40 to 76. The values obtained from a quantitative study of content validity, based on the content validity ratio and content validity index, were greater than 0.78 and 0.9, respectively. The Cronbach’s α (internal consistency index) and Spearman-Brown coefficient (which indicates split-half reliability) for the questionnaire dimensions were estimated to be greater than 0.84 and 0.79, respectively [27].
Given that the distribution of variables did not follow a normal distribution, Spearman’s correlation coefficient, the Mann-Whitney test, and the Kruskal-Wallis test were used to analyze the data. The data were analyzed using SPSS software, version 21. A P<0.05 was considered statistically significant.

Results 
This study was conducted on 369 retired elderly men, with a mean age of 66.5±4.7 years, a minimum age of 60 years, and a maximum age of 85 years.
The mean total sexual health score of the elderly participants studied was 92.22±12.95 (maximum-minimum: 48-117). Their mean score in the erectile domain was 10.88±3.87 (72.7% of the maximum score). Additionally, based on the cut-off point for erectile dysfunction, a score of less than or equal to 2 is considered indicative of erectile dysfunction [28]. Furthermore, 17.1% of the elderly participants had erectile dysfunction. The average score of discomfort due to erectile dysfunction (where a higher score indicates less discomfort) was 4.48±0.94 and the majority of cases (72.9%) reported that they were not bothered at all or had no problems.
The mean ejaculation score of the elderly men was 26.87±6.29 (76.9% of the maximum score). The mean score of discomfort due to the inability to ejaculate (where a higher score indicates less discomfort) among the elderly participants was 4.67±0.74 and the majority (79.7%) reported that they had no discomfort in this regard.
The elderly participants studied obtained an average score of 22.84±3.56 (76% of the maximum score) in sexual satisfaction. Additionally, an average of 54.6% of the subjects expressed moderate satisfaction with the sexual satisfaction questions. The majority of the elderly (59.1%) reported having sexual intercourse between 1 and 3 times a month, while only 35 individuals (9.5%) had no sexual contact in the past month. Furthermore, for 39.4% of the participants, the last sexual intercourse occurred between 1 and 3 months ago. The elderly subjects identified erectile dysfunction (31.4%), ejaculation dysfunction (17.4%) and other causes (51.43%) as reasons for not having sex.
Since the distributions of erection, ejaculation, and sexual satisfaction did not follow a normal distribution according to the Kolmogorov-Smirnov test, Spearman’s correlation coefficient was used to analyze the data. The ejaculation score had a positive and significant correlation with erection (P<0.001, r=0.531) and satisfaction (P<0.001, r=0.189). Additionally, the correlation of the erection score with satisfaction (P<0.001, r=0.231) was statistically significant and positively correlated.
Regarding the effect of other variables, the average erection score was statistically significantly correlated with job, age, place of residence, age gap between couples, duration of married life, physical and medical illnesses and use of certain medications (P<0.05). Additionally, the average ejaculation score was statistically significantly correlated with age, the age gap between couples, and the duration of married life (P<0.05).
The mean sexual satisfaction score was significantly correlated with employment status, duration of marital life, and family income (P<0.05). Employed individuals had a higher mean sexual satisfaction score than retired individuals. Elderly individuals with lower family income had a higher mean sexual satisfaction score, while the mean sexual satisfaction score decreased with increasing duration of marital life.

Conclusion 
More than 80% of the elderly participants did not have erectile dysfunction, and the erection and ejaculation scores of the elderly were more than 70% of the maximum possible score. In terms of sexual satisfaction, more than half of them were moderately satisfied with their sex life. The better the elderly performed in the areas of erection and ejaculation, the greater their sexual satisfaction. Erectile function was significantly correlated with occupation, age, place of residence, age gap between couples, duration of married life, physical and medical illnesses, and use of certain medications. Ejaculatory dysfunction was also significantly correlated with age, the age gap between couples, and the duration of married life. Sexual satisfaction was significantly correlated with employment status, duration of married life, and family income. Given that there was a relationship between sexual function and satisfaction with some demographic characteristics, it is recommended that screening and identification of sexual problems in the elderly be included in the country’s health policies.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Guilan University of Medical Sciences, Rasht, Iran (Ethics Code: IR.GUMS.REC.1398.049).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Writing the original draft and supervision: Elahe Abdolhai and Somayeh Shokgar; Statistical analysis: Ehsan Kazemnejad-Leili; Data collection: Daniyal Moradi and Mohammad Hossein Abbasalizadeh; Conceptualization, study design and critical review: All authors.

Conflicts of interest
All authors contributed equally to the conception and design of the study, data collection and analysis, interpretation of the results, and drafting of the manuscript. Each author approved the final version of the manuscript for submission.

Acknowledgements
The authors would like to express their gratitude to the Gilan Provincial Pensioners Association.


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