"In the End You Keep Silent": Help-Seeking Behavior Upon Sexual Victimization in Older Adults.

Sexual violence is considered a prominent mental health problem. Exposure to sexual victimization during lifetime has been linked to mental health problems in old age. Research in adult victims has shown that they experience many barriers for disclosure and seeking professional help upon sexual victimization. However, information on help-seeking behavior in older victims of sexual violence is non-existent. With this study we aim for a better understanding of help-seeking behavior upon sexual violence in older adults. We used a mixed methods approach with an explanatory sequential design. Data were collected through structured face-to-face interviews with a random sample of 227 sexual violence victims of 70 years and older living in Belgium. Quantitative data were triangulated with qualitative data from 15 in-depth interviews with older victims. We found that up to 60% of older sexual violence victims never disclosed their experiences and 94% never sought professional help. Help-seeking is a complex process comprising several phases, which are affected by strong feelings of shame and self-blame, ageist premises and taboos about sexuality. In the end, most victims choose to cope on their own. Occasional disclosure only happens decades after the sexual violence took place. Older victims do not spontaneously disclose to healthcare workers but expect professionals to initiate the conversation. In conclusion, few older victims disclose or seek professional help upon sexual victimization. Healthcare professionals working with older adults need capacity building through training, screening tools, and care procedures to initiate conversation on sexual violence, and to detect signs, prevent, mitigate and respond to sexual victimization in older adults.

"Just something that happened?": Mental health impact of disclosure and framing of sexual violence in older victims.

INTRODUCTION: Despite the important impact of sexual violence (SV) on mental health, few victims disclose their experiences. Although research in adult victims suggests that SV disclosure could protect against long-term mental health problems, studies in older adults are lacking. OBJECTIVES: To establish the prevalence of depression, anxiety, posttraumatic stress disorder (PTSD), suicide attempts, and self-harm, their association with SV disclosure, and the moderating effect of sociodemographic characteristics and SV framing in the relation between SV disclosure and the different mental health outcomes in older SV victims. METHODS: Data on sexual victimisation, mental health, SV framing, and disclosure were collected through structured face-to-face interviews with 171 randomly selected sexually victimised adults of 70 years and older living in Belgium. SV was measured using behaviourally specific questions based on a broad definition. Mental health outcomes were measured using validated scales. RESULTS: Depression, anxiety and PTSD were reported by 34%, 33% and 9% of participants respectively, 5% had attempted suicide and 1% reported self-harm during lifetime. SV framing was associated with the kind of help victims consulted. SV disclosure was not linked with depression and anxiety, but was associated with an increase of PTSD symptoms in older victims with care dependency (p = 0.004) or a chronic illness and/or disability (p = 0.025). CONCLUSIONS: SV disclosure in itself does not protect against adverse mental health outcomes in old age. Capacity building of professionals trough training and development of clinical guidelines and care procedures may increase appropriate response to SV disclosure by older victims.

Mental health of sexual assault victims and predictors of their use of support from in-house psychologists at Belgian sexual assault care centres.

BACKGROUND: Sexual assault (SA) can induce a negative impact on victims' mental health. Specialised SA services generally offer medical care and a forensic examination to SA victims. However, there is a large variation in how these services provide mental health support. OBJECTIVE: This study aims to assess mental health problems of SA victims attending the Belgian Sexual Assault Care Centres (SACCs) and identify predictors for victims' use of support from in-house psychologists. METHOD: Health records of victims ≥ 16 years who presented within one week post-SA to one of the three Belgian SACCs between 25 October 2017 and 31 October 2019 were reviewed. An AIC-based stepwise backward binary logistic regression was used to analyse the association between victim, assault, service use and mental health characteristics and follow-up by a SACC-psychologist. RESULTS: Of the 555 victims, more than half had a history of mental health problems. Of those assessed, over 70% showed symptoms of posttraumatic stress disorder (PTSD), depression and/or anxiety disorder. One in two victims consulted a SACC-psychologist. Victims with a mental health history (OR 1.46, p = .04), victims accompanied by a support person during acute care (OR 1.51, p = .04), and victims who were assaulted by an acquaintance in comparison to those assaulted by a stranger (OR 1.60, p = .039) were more likely to attend their appointment with the SACC-psychologist. CONCLUSION: The study reaffirms the high mental health burden among victims attending specialised SA services, stressing the need to provide effective mental health interventions at these services and improve their longer-term use by victims. Prescheduling of appointments with an in-house psychologist in combination with phone reminders may improve the uptake of such services. Health care providers must be vigilant about potential barriers faced by victims without a mental health history or social support in attending appointments with mental health professionals.

The mental health burden is high among victims attending Belgian Sexual Assault Care Centres.Half of the victims use the support of an in-house psychologist. Victims with a history of mental health problems, those accompanied by a support person during acute care, and those assaulted by an acquaintance in comparison to those assaulted by a stranger, are more likely to use this support.Effective mental health support should be recognised as an integral and essential part of care for SA victims. Uptake and longer-term engagement with this mental health support should be improved for those victims diagnosed with PTSD.

An ecological approach to understanding the impact of sexual violence: a systematic meta-review.

Aim: A systematic meta-review was conducted to examine (1) the broad range of negative and positive individual and interpersonal changes following adult sexual violence, as well as (2) the risk/protective factors at multiple levels of the social ecology (e.g., individual, assault, and micro/meso/exo/macro/chronosystem factors)-influencing the impact of sexual violence. Methods: Searches of Web of Science, Pubmed, and ProQuest resulted in inclusion of 46 systematic reviews or meta-analyses. Review findings were extracted for summary and a deductive thematic analysis was conducted. Results: Experiencing sexual violence is associated with many negative individual and sexual difficulties as well as revictimization risk. Only a limited number of reviews reported on interpersonal and positive changes. Factors at multiple levels of the social ecology play a role in the intensity of these changes. Reviews including macrolevel factors were non-existent, however. Conclusion: Reviews on sexual violence are fragmented in nature. Although the use of an ecological approach is often lacking, adopting such a perspective in research is necessary for a fuller understanding of the multiple influences on survivor outcomes. Future research should evaluate the occurrence of social and positive changes following sexual violence, as well as the role of macrolevel factors in influencing post-assault outcomes.

Factors Related to Police Reporting in Sexual Assault Care Centers: Are We Underestimating the Role of Support Persons?

Few victims of sexual assault (SA) report to the police. Research on the role of support persons in victims' reporting is sparse. We address this gap by examining the association of victim, assailant, victimization incident, and support characteristics with reporting rates among victims attending sexual assault care centers (SACCs). Logistic regression results show that type of SA, delay between SA and presentation at SACC, and presence of an informal support person at SACC and SACC site are significantly associated with police reporting. These findings reveal the importance of targeting victims' support persons to alter reporting behavior among SA victims.

Exploring Sociodemographic and Mental Health Differences Among Constructed Male Victim Severity Profiles.

Stigmas and taboos surrounding male sexual violence, stating that men cannot be sexually victimized and would not experience many adverse effects as a result, continue to shroud the issue of male sexual victimization (SV). Male victims, therefore, remain under-recognized in research, policy, and treatment provisions. Furthermore, knowledge regarding male SV is severely compromised by studying male victims in convenience samples with a focus on hands-on forms of sexual violence. Finally, severity of SV is often described using a one-dimensional approach based on presumed severity leading to an oversimplified image. This study addresses these various gaps in scientific research by constructing severity profiles of male SV based on self-reported consequences, prevalence, and co-occurrence of SV. A total of 1,078 male victims were selected from a Belgian nationally representative sample collected between October 2019 and January 2021. Profiles are constructed using latent class analysis. Sociodemographic differences across the profiles are examined through multinomial regression analysis. Finally, differences in current mental health problems across the profiles are assessed. Four distinct male victim profiles are identified: (a) low severity-low victimization (58.3%), (b) medium severity-hands-off victimization (21.4%), (c) medium severity-poly-victimization (13.3%), and (d) high severity-poly-victimization (7.0%). Group comparisons show how male victims in the high-severity class report significantly higher rates of mental health problems such as depression, anxiety, and suicide and/or self-harm. Significant differences in class membership were found for age, occupational status, relationship status, sexual orientation, and financial status. This study provides new insights in the patterns of male SV and highlights the presence of poly-victimization among male victims. Additionally, we point out how the so-called minor forms of SV (i.e., hands-off SV) can have a large effect on male victims. The study ends with suggestions for care and future research.

Screening for and Disclosure of Domestic Violence during the COVID-19 Pandemic: Results of the PRICOV-19 Cross-Sectional Study in 33 Countries.

The COVID-19 pandemic left no one untouched, and reports of domestic violence (DV) increased during the crisis. DV victims rarely seek professional help, yet when they do so, they often disclose it to their general practitioner (GP), with whom they have a trusting relationship. GPs rarely screen and hence rarely take the initiative to discuss DV with patients, although victims indicate that offering this opportunity would facilitate their disclosure. This paper aims to describe the frequency of screening for DV by GPs and disclosure of DV by patients to the GP during the COVID-19 pandemic, and to identify key elements that could potentially explain differences in screening for and disclosure of DV. The PRICOV-19 data of 4295 GP practices from 33 countries were included in the analyses, with practices nested in countries. Two stepwise forward clustered ordinal logistic regressions were performed. Only 11% of the GPs reported (much) more disclosure of DV by patients during COVID-19, and 12% reported having screened for DV (much). Most significant associations with screening for and disclosure of DV concerned general (pro)active communication. However, (pro)active communication was performed less frequently for DV than for health conditions, which might indicate that GPs are insufficiently aware of the general magnitude of DV and its impact on patients and society, and its approach/management. Thus, professional education and training for GPs about DV seems highly and urgently needed.

The links of stress, substance use and socio-demographic factors with domestic violence during the Covid-19 pandemic in Portugal.

BACKGROUND: Lockdown, as a measure implemented to combat the coronavirus disease 2019 (COVID-19) pandemic, left many domestic violence (DV) victims trapped with their abusers. This study intends to explore the links between perceived stress, substance use and socio-demographic factors with DV experiences during COVID-19 pandemic in Portugal. METHODS: A cross-sectional study was carried out on a sample of 1062 participants over 16 years old, residing in Portugal. Data were collected through an online survey conducted between April and October 2020. The associations between potential factors and DV were investigated using bivariable analysis and multivariable logistic regression. RESULTS: The prevalence of DV reported was 13.75% (n = 146), disaggregated into psychological violence (13%, n = 138), sexual violence (1.0%, n = 11) and physical violence (0.9%, n = 10). Multivariable analyses confirmed that perceived financial difficulties (OR = 1.608; P = 0.019), use of medications to sleep or calm down (OR = 1.851; P = 0.002) and perceived stress (OR = 2.443; P = 0.003) were responsible for DV exposure during COVID-19 pandemic. Younger age (<25 years old) and consumption of alcohol were associated with a higher risk of DV victimization. CONCLUSIONS: Interventions aimed at preventing and confronting DV are necessary within the strategies to combat COVID-19 in Portugal, especially aimed at groups in vulnerable situations, during and after the pandemic.

Victimization of Applicants for International Protection Residing in Belgium: Sexual Violence and Help-Seeking Behavior.

BACKGROUND: Sexual violence (SV) literature on applicants for international protection (AIPs) shows that they are at high risk of victimization. The study objectives are to provide an exploratory overview of the occurrence of SV in AIPs in Belgium and their help-seeking behavior (HSB). This overview is crucial to develop prevention strategies and care paths focusing on providing adequate care to AIP SV victims in Belgium. METHODS: Quantitative data from structured interviews with AIPs (n = 62) triangulated with qualitative data from in-depth interviews with AIP SV victims (n = 11) served to explore the nature and impact of SV in AIPs in Belgium and their HSB. RESULTS: A total of 83.9% of respondents have experienced SV. A total of 61.3% were victimized within the past year. Victimization seems more gender-balanced than in the general population. AIPs link SV to their legal status and their associated vulnerable situation. HSB upon SV was very limited in this sample. Help-seeking barriers interfering with the decision-making process to consult (in)formal resources were identified. CONCLUSIONS: AIPs in Belgium are at high risk of SV. Despite the impact of SV on AIPs' lives, HSB upon SV is rare. The provision of age-appropriate sexual education and development of policies that will reduce help-seeking barriers is needed.

Locked up at home: a cross-sectional study into the effects of COVID-19 lockdowns on domestic violence in households with children in Belgium.

BACKGROUND: Policymakers worldwide took measures to limit the spread of the COVID-19-virus. While these sanitary measures were necessary to fight the spread of the virus, several experts warned for a significant impact on mental health and a potential increase in domestic violence. To study the impact of the COVID-19 measures in Belgium, and the factors influencing the occurrence of domestic violence, we set up the study on relationships, stress, and aggression. In this study, we evaluate the prevalence of domestic violence victimization during the COVID-19 lockdown in Belgian children aged zero to seventeen years and the associations of the parents' financial status, relationships, mental health, and previous victimization to the child's victimization. METHODS: A stepwise forward binary logistic regression was used to analyse the association between multiple risk factors of domestic violence and victimization of the respondent's child. The respondent being an assailant, the respondent's age, and the age of the children in the household were added as moderators. RESULTS: In this model an association with domestic child abuse was found for the age of the respondent, the household's size, the presence of children between zero and five years in the household, the perceived stress level of the respondent, and victimization of the respondent during the first wave of the sanitary measures, as well as victimization before the COVID-19 pandemic. None of the interacting effects were found to be significant. CONCLUSION: It is advisable to make extra efforts to improve well-being when maintaining sanitary measures by providing appropriate assistance and helping households struggling with increased or acute stress to install positive coping strategies - especially in larger households with children between six and 17 years. Besides, our findings draw attention to the clustering of risk of child and adult violence exposure in lockdown situations as well as to the potential cumulative impact of exposure to violence across the lifespan and across generations. It is key to invest in training healthcare workers and staff at schools to screen for and assess risks of domestic violence development and ongoing or past occurrence in order to detect, refer and follow-up on families at risk.

An assessment of the proportion of LGB+ persons in the Belgian population, their identification as sexual minority, mental health and experienced minority stress.

BACKGROUND: Previous studies report vast mental health problems in sexual minority people. Representative national proportion estimates on self-identifying LGB+ persons are missing in Belgium. Lacking data collection regarding sexual orientation in either census or governmental survey data limits our understanding of the true population sizes of different sexual orientation groups and their respective health outcomes. This study assessed the proportion of LGB+ and heterosexual persons in Belgium, LGB+ persons' self-identification as sexual minority, mental health, and experienced minority stress. METHOD: A representative sample of 4632 individuals drawn from the Belgian National Register completed measures of sexual orientation, subjective minority status, and its importance for their identity as well as a range of mental-health measures. RESULTS: LGB+ participants made up 10.02% of the total sample and 52.59% of LGB+ participants self-identified as sexual minority. Most sexual minority participants considered sexual minority characteristics important for their identity. LGB+ persons reported significantly worse mental health than heterosexual persons. Sexual minority participants did not report high levels of minority stress, but those who considered minority characteristics key for their identity reported higher levels of minority stress. LGB+ participants who did not identify as minority reported fewer persons they trust. CONCLUSIONS: The proportion of persons who identified as LGB+ was twice as large as the proportion of persons who identified as a minority based on their sexual orientation. LGB+ persons show poorer mental health compared to heterosexual persons. This difference was unrelated to minority stress, sociodemographic differences, minority identification, or the importance attached to minority characteristics.

Extreme events and gender-based violence: a mixed-methods systematic review.

The intensity and frequency of extreme weather and climate events are expected to increase due to anthropogenic climate change. This systematic review explores extreme events and their effect on gender-based violence (GBV) experienced by women, girls, and sexual and gender minorities. We searched ten databases until February, 2022. Grey literature was searched using the websites of key organisations working on GBV and Google. Quantitative studies were described narratively, whereas qualitative studies underwent thematic analysis. We identified 26 381 manuscripts. 41 studies were included exploring several types of extreme events (ie, storms, floods, droughts, heatwaves, and wildfires) and GBV (eg, sexual violence and harassment, physical violence, witch killing, early or forced marriage, and emotional violence). Studies were predominantly cross-sectional. Although most qualitative studies were of reasonable quality, most quantitative studies were of poor quality. Only one study included sexual and gender minorities. Most studies showed an increase in one or several GBV forms during or after extreme events, often related to economic instability, food insecurity, mental stress, disrupted infrastructure, increased exposure to men, tradition, and exacerbated gender inequality. These findings could have important implications for sexual-transformative and gender-transformative interventions, policies, and implementation. High-quality evidence from large, ethnographically diverse cohorts is essential to explore the effects and driving factors of GBV during and after extreme events.

The Implication of the First Wave of COVID-19 on Mental Health: Results from a Portuguese Sample.

The social conditions created by the COVID-19 pandemic had a great potential to affect the mental health of individuals. Meta-analyses indicate a rise in these problems in these periods among general populations, patients and health professionals, even with substantial heterogeneous results. This paper examines mental health impacts specifically during the first wave of COVID-19. An online survey was conducted with a Portuguese convenience sample (N = 1.062) comprising questions about substance use, perceived stress, post-traumatic stress disorder and self-damage behaviors. The results concerning substance use show an extensive use of medication to sleep or calm down, especially among women and older respondents, a small percentage of alcohol consumers with a high pattern of use and less frequent cannabis consumption, even with a quarter of users who began only in the COVID-19 period. The rates of perceived stress and PTSD were higher compared with international prevalence estimations during the pandemic conditions. Both correlated measures were worse for women and young people. Another problematic issue was the rate of suicidal ideation, with a relevant proportion of starters during this period. These data reinforce the need to promote access to mental health services.

Minority Identity, Othering-Based Stress, and Sexual Violence.

BACKGROUND: Some (minority) groups (MGs) are more vulnerable to sexual violence (SV) exposure than others. Othering-based stress (OBS) may mediate the relationship between minority identification and SV. This study aims to assess the prevalence of SV in different MGs to explore the relationship between minority identification and SV, to investigate whether belonging to multiple MGs moderates this relationship, and to explore OBS SV moderation for different MGs. METHOD: Through an online survey administered to a nationally representative sample in Belgium, data was collected from 4632 persons, of whom 21.01% self-identified as belonging to a MG (SI-Minority). SV prevalence was measured using behaviorally specific questions based on the WHO definition of SV. SI-Minority participants received an additional scale on OBS. RESULTS: SI-Minority participants reported more SV victimization compared to the non-minorities. However, this increased risk was not moderated by minority identification but linked to the socio-demographic SV risk markers common to minority individuals. Multiple-minority participants were found more at risk of SV compared to single-minority respondents. Lesbian, gay, bisexual, pan-/omnisexual, asexual, and other non-heterosexual (LGB+) participants were found more at risk than heterosexual participants. OBS was found to be significantly correlated to SV in sexual and gender minorities and in cultural minorities. CONCLUSIONS: This study contributes to our understanding of the relationship between minority identification, OBS, and SV. Studying both specific and common SV vulnerabilities and outcomes within specific societal subgroups and the general population may inform policy makers when allocating resources to those interventions with the largest societal impact.

"Time Does Not Heal All Wounds": Sexual Victimisation Is Associated with Depression, Anxiety, and PTSD in Old Age.

Sexual violence (SV) has an important impact on mental health. Childhood sexual abuse is linked to internalising disorders in later life. In older adults, SV occurs more often than previously believed. Moreover, health care workers lack the skills to address SV in later life. Studies researching the mental health impact of lifetime SV, i.e., SV during childhood, adulthood, and old age, are lacking. Between July 2019 and March 2020, 513 older adults living in Belgium participated in structured face-to-face-interviews. Selection occurred via a cluster random probability sampling with a random walk finding approach. Depression, anxiety, and posttraumatic stress syndrome (PTSD) were measured using validated scales. Participants were asked about suicide attempts and self-harm during their lifetime and in the past 12 months. SV was measured using behaviourally specific questions based on a broad SV definition. We found rates for depression, anxiety, and PTSD of 27%, 26%, and 6% respectively, while 2% had attempted suicide, and 1% reported self-harm in the past 12 months. Over 44% experienced lifetime SV and 8% in the past 12 months. Lifetime SV was linked to depression (p = 0.001), anxiety (p = 0.001), and PTSD in participants with a chronic illness/disability (p = 0.002) or no/lower education (p < 0.001). We found no link between lifetime SV and suicide attempts or self-harm in the past 12 months. In conclusion, lifetime SV is linked to mental health problems in late life. Tailored mental health care for older SV victims is necessary. Therefore, capacity building of professionals and development of clinical guidelines and care procedures are important.

Sexual Activity and Physical Tenderness in Older Adults: Prevalence and Associated Characteristics From a Belgian Study.

BACKGROUND: Despite the World Health Organization calling for sexuality to be recognized as an aspect of well-being, no studies have explored sexual activity and physical tenderness in older adults aged ≥ 75 years in Belgium or those aged ≥ 85 years worldwide. AIM: To assess the prevalence and predictors of sexual activity and physical tenderness in a sample of older adults. METHODS: Using data from a Belgian cross-sectional study on sexual violence (UN-MENAMAIS), information on sexual activity, physical tenderness, and associated characteristics was collected during structured face-to-face interviews with older adults living in the community, assisted living facilities, or nursing homes. Cluster random probability sampling with a random route-finding approach was used to select the participants. OUTCOMES: Current sexual activity and physical tenderness in the previous 12 months, sociodemographic characteristics, chronological age, subjective age, number of sexual partners, sexual satisfaction, attitudes toward sexuality in later life, quality of life, and lifetime sexual victimisation. RESULTS: Among the 511 participants included, 50.3% were in a relationship, mainly living with their partner; 31.3% indicated they were sexually active; and 47.3% of sexually inactive participants reported having experienced forms of physical tenderness in the previous 12 months. Sexual activity was associated with the presence of a partner, satisfaction with sexual life, permissive attitudes regarding sexuality in later life, a younger age, and a lack of disability. Physical tenderness was associated with the presence of a partner, community residency, and permissive attitudes regarding sexuality in later life. CLINICAL IMPLICATIONS: Raising awareness among the general population, healthcare professionals, and older adults about sexuality in later life could contribute to ending this taboo and should therefore be a priority for society. STRENGTHS AND LIMITATIONS: Our study fills a gap in the literature regarding sexual activity and physical tenderness in older adults aged ≥ 70 years, including respondents aged up to 99 years. Additionally, we explored different forms of sexual expression beyond intercourse, and face-to-face interviews contributed to the quality of the collected data. The main limitation of this study was the sample size, although the findings were similar to recent statistical indicators in Belgium. CONCLUSION: One in 3 older adults aged ≥ 70 years living in Belgium are sexually active. These findings provide an opportunity to inform the general public and older adults about later life sexuality and to educate healthcare professionals about aging sexuality to increase discussions and avoid assumptions of asexuality in later life. Cismaru-Inescu A, Hahaut B, Adam S et al. Sexual Activity and Physical Tenderness in Older Adults: Prevalence and Associated Characteristics From a Belgian Study. J Sex Med 2022;19:569-580.

Research in Hard-to-Reach Populations: Challenges and Strategies for Conducting Sexual Violence Studies in Applicants for International Protection Beyond the European General Data Protection Regulation.

BACKGROUND: Conducting research in hard-to-reach populations such as applicants for international protection (AIPs) brings along a number of research challenges. This is especially true for sexual violence (SV) research. METHODS: We developed a study design with the intent to reach AIPs in a randomized and anonymous manner including potential illiterate respondents as well, while avoiding as much bias as possible. However, this method was developed just before the entry into force of the new European General Data Protection Regulation (GDPR), upon which important new research challenges emerged. RESULTS: This paper describes the original study design developed to estimate SV prevalence in AIPs in Belgium. We discuss the impact of the GDPR on the recruitment strategy applied to conduct a survey on SV in a randomly selected sample of AIPs, the adapted approach to conduct the study beyond GDPR and lessons learned for future research on sensitive topics in hard-to-reach populations such as AIPs. CONCLUSION: To achieve reliable prevalence numbers and provide high-quality data on SV in AIPs while respecting the GDPR regulations, studies will require an approach that has become significantly more time consuming and resource-intensive to implement.

Challenges in Conducting Sexual Health and Violence Research in Older Adults Beyond the General Data Protection Regulation: A Belgian Case Study.

Because of a growing older population, the sexual health (SH) of older adults, including sexual violence (SV), is becoming an increasingly important public health concern. Yet, reliable SV prevalence rates and risk factors are lacking, due to methodological shortcomings in current studies. SV research involves challenges regarding safety and disclosure, especially in older adults. In this paper, we reflect on the methods used in a sexual health and violence (SH&V) study in older adults balancing between privacy rules imposed by the General Data Protection Regulation (GDPR) and ethical and safety guidelines.To ensure the acceptability of the questionnaire, it was tested in a two-phase pilot study. To maximize SV disclosure, the questionnaire built up gradually towards the more sensitive SV modules. Interviewers were trained to approach participants in a non-judgmental manner. Due to GDPR, our data collection method was changed from a random sampling via the National Register to a cluster random probability sampling with a random walk finding approach.Older adults were willing to discuss SH&V during a structured face-to-face interview with trained interviewers. Following strict safety guidelines, no major incidents were reported. The cluster random probability sampling with random walk finding approach provided an adequate sampling frame, but was inefficient and time-consuming.Doing research on SH&V in older adults is feasible but requires a substantial investment of time and the challenges involved may incur greater costs. In order to guarantee further research on sensitive topics in older adults, we recommend that an interdisciplinary expert group consisting of researchers, donors, and policymakers investigates how GDPR and public health research in hard-to-reach populations can be better matched.

The Elephant in the Room - A Critical Interpretive Synthesis of Older Adults' Sexuality.

Objectives: This study aimed to explore past studies that have focused exclusively on the sexuality of adults older than 65 from a positive public health approach. Methods: We performed a critical interpretive synthesis, starting with the literature review on sexual behaviors in later life, adding policy documents on aging sexuality, and bringing new perspectives. Results: Older adults continue to be sexually active. Healthcare professionals lack knowledge and communication skills surrounding aging sexuality and no policies before 2013 mention aging sexuality. Conclusions: We posit that society's view of later life sexuality reflects on practice, policies, and research on this topic, which influence back society's view.