Aging Sexual Knowledge and Attitudes Scale

1. Abstract

The Aging Sexual Knowledge and Attitudes Scale (ASKAS) is a seminal psychometric instrument developed by Charles B. White to assess objective factual knowledge and sociosexual attitudes concerning sexuality in late adulthood. Comprising 61 items, the scale is divided into two distinct dimensions: a 35-item Knowledge subscale utilizing a trichotomous response format (True, False, Don’t Know) and a 26-item Attitude subscale evaluated through a 7-point Likert-type scale ranging from 1 (Strongly Disagree) to 7 (Strongly Agree). The instrument was specifically constructed to address the absence of specialized measures capable of capturing the biological, physiological, and psychosocial realities of geriatric sexuality, moving beyond generalized sexual knowledge indices that overlook the aged population. Scoring protocols are uniquely structured such that lower composite scores indicate greater empirical knowledge and more permissive, affirming attitudes toward late-life sexuality. Extensively validated across institutionalized nursing home residents, community-dwelling older adults, multidisciplinary healthcare providers, and family caregivers, the ASKAS demonstrates exceptional psychometric robustness. Internal consistency estimates across diverse cohorts reveal Cronbach’s alpha coefficients ranging from .90 to .93 for the Knowledge subscale and .76 to .87 for the Attitude subscale, supplemented by test-retest reliability coefficients between .72 and .97. Factor analytic evaluations support a stable two-factor orthogonal model corresponding cleanly to the knowledge and attitude domains. As an evaluative outcome tool, the ASKAS possesses pronounced sensitivity to intervention effects, consistently demonstrating significant pretest-to-posttest shifts following psychoeducational programs. This comprehensive article provides an in-depth analysis of the theoretical foundations, structural dimensionality, validity evidence, scoring mechanics, and clinical applications of the ASKAS.

2. Keywords

Aging Sexual Knowledge and Attitudes Scale, ASKAS, geriatric sexuality, sexual knowledge, sexual attitudes, psychometrics, nursing home residents, healthcare education, late-life intimacy, sexual gerontology

3. Authors

The Aging Sexual Knowledge and Attitudes Scale was developed by Charles B. White, Ph.D., Department of Psychology, Trinity University, San Antonio, Texas, United States. Correspondence regarding historical inquiries and instrument data sharing may be directed to Charles B. White, Trinity University, 1 Stadium Drive, San Antonio, TX 78212 (e-mail: [email protected]).

4. Purpose

The late-twentieth-century emergence of gerontology and sexual medicine exposed pervasive cultural biases, ageist stereotypes, and institutional neglect regarding late-life intimacy. Historically, older individuals were culturally categorized as asexual, while those expressing romantic or erotic desires were frequently stigmatized, pathologized, or subjected to infantilizing surveillance. Prior to the development of the ASKAS, existing sexuality assessment instruments—such as the Sex Knowledge and Attitude Test (SKAT)—were primarily normed on medical students and younger adult populations. These general inventories lacked sensitivity to the normative biological alterations of the aging reproductive system, the pharmacological side effects common in multimorbid geriatric populations, and the complex institutional dynamics of long-term care facilities.

The primary purpose of the Aging Sexual Knowledge and Attitudes Scale is to provide an empirically grounded, dual-realm instrument specifically dedicated to the aging population. It serves several core functions:

• Evaluating Psychoeducational Interventions: The ASKAS was constructed as an evaluative pretest-posttest outcome measure to evaluate the efficacy of structured training programs designed to enhance factual knowledge and dismantle restrictive attitudes among older adults, clinical staff, and family members (White & Catania, 1981).
• Facilitating Clinical and Group Discussions: Individual item analysis allows clinicians, social workers, and sex therapists to pinpoint specific knowledge deficits and ideological barriers, using them as structured prompts for therapeutic dialogue in residential and outpatient settings.
• Staff Training in Long-Term Care: The scale serves as a diagnostic tool in nursing homes, assisted living facilities, and palliative care centers to identify institutional prejudices, restrictive care practices, and staff educational needs concerning resident intimacy and privacy rights.
• Investigating Behavioral Correlates: The instrument facilitates empirical research examining how cognitive comprehension of physiological aging and personal moral frameworks correlate with actual sexual activity, relationship satisfaction, and mental health in later life (White, 1982a).

5. Psychological Construct

The ASKAS conceptualizes sexuality in old age not merely as physical intercourse, but as a multidimensional biopsychosocial phenomenon encompassing intimacy, emotional closeness, physiological adaptability, and personal values. The scale delineates this phenomenon into two core domains:

5.1. Aging Sexual Knowledge (35 Items)

The Knowledge dimension assesses objective factual comprehension of physiological, biological, pharmacological, and psychological factors governing sexual functioning in older adults (conventionally defined as individuals aged 65 and older). This domain challenges prevalent myths by evaluating awareness of normative physiological slowing versus pathological dysfunction:

• Male Age-Related Physiological Changes: Comprehension of normative changes such as prolonged time required to achieve erection, reduced ejaculatory urgency, decreased orgasmic intensity, and decreased penile rigidity (e.g., Items 2, 3, 4, 19).
• Female Age-Related Physiological Changes: Knowledge of post-menopausal biological realities, including reduced and delayed vaginal lubrication, thinning of vaginal walls, potential dyspareunia, and the persistence of orgasmic capacity (e.g., Items 5, 6, 7, 31).
• Systemic and Pharmacological Interactions: Awareness of how chronic conditions, cardiovascular health, psychological depression, prescription medications, alcohol, tranquilizers, and nicotine intake impact libido and erectile competence (e.g., Items 9, 16, 22, 23, 26).
• Continuity and Psychosocial Determinants: Recognition that sexual interest is lifelong, that prior sexual frequency predicts late-life activity (the continuity hypothesis), and that cessation of intimacy is driven primarily by psychosocial barriers, partner availability, and performance anxiety rather than absolute biological decay (e.g., Items 8, 11, 27, 28, 29, 34).

5.2. Aging Sexual Attitudes (26 Items)

The Attitude dimension captures evaluative stances, moral frameworks, and tolerance levels regarding sexual behavior among older individuals. It spans personal, familial, and institutional contexts:

• Institutional Policies and Environmental Privacy: Attitudes concerning whether nursing homes and long-term care environments should support resident intimacy, provide double beds, respect physical privacy without intrusion, or segregate residents by gender (e.g., Items 38, 39, 40, 54, 59).
• Societal and Moral Sanctions: Beliefs regarding the propriety of recreational sex, non-marital relationships, and masturbation among older men and women, contrasting permissive viewpoints with moral condemnation (e.g., Items 37, 46, 52, 53, 58, 61).
• Family Dynamics and Proxy Interference: Familial reactions to late-life romance, evaluating whether adult children and relatives should respect an older individual’s autonomy or actively intervene, complain, and demand separation (e.g., Items 42, 43, 44, 45, 60).
• Educational Receptivity: Openness to sex education programs for older residents, healthcare professionals, and paraprofessional care staff (e.g., Items 47, 50, 51, 55).

6. Theoretical Framework

The construction of the ASKAS is grounded in foundational principles of sexual physiology, lifespan development, and social gerontology:

6.1. Human Sexual Response and Age-Related Physiology

The physiological baseline of the ASKAS Knowledge domain rests largely upon the pioneering empirical work of William H. Masters and Virginia E. Johnson (1966, 1970). Masters and Johnson established that while sexual response slows with age—characterized by longer excitement phases, diminished vasocongestion, and altered orgasmic platforms—the physiological capacity for sexual expression and pleasure remains intact across the lifespan. The ASKAS translates these laboratory findings into objective test items, distinguishing natural biological maturation from treatable secondary dysfunction.

6.2. Continuity Theory of Aging

From a sociological and lifespan developmental perspective, the scale aligns with Continuity Theory, formulated by Robert Atchley (1971, 1989). Continuity theory posits that aging individuals adapt by maintaining established patterns of thought, lifestyle behaviors, interpersonal attachments, and identity markers from earlier adulthood. Applied to sexuality, the ASKAS reflects the empirical reality that older adults who were sexually active and invested in intimacy during young adulthood and midlife typically maintain sexual interest and behavior into advanced old age, provided their health and access to partners permit (Item 11).

6.3. The Biopsychosocial Model and Ageism

The ASKAS Attitude dimension is rooted in the conceptualization of institutional ageism formulated by Robert N. Butler (1969, 1975). Butler demonstrated that negative stereotypes concerning late-life sexuality generate institutional policies that actively disenfranchise older adults. In residential care facilities, infantilizing administrative policies often classify normative sexual behavior as disruptive, demented, or pathologically inappropriate. The ASKAS provides an empirical framework to quantify these societal biases and evaluate whether educational interventions can foster supportive residential environments.

7. Validity

The psychometric validity of the ASKAS has been substantiated through construct, criterion-related, and intervention-based experimental studies across varied populations:

7.1. Construct and Factorial Validity

In his psychometric validation studies, White (1982b) conducted principal components factor analysis with varimax rotation across combined cohorts comprising nursing home residents, community-dwelling older adults, long-term care staff, and family members. The empirical findings demonstrated a robust two-factor structure. Items hypothesized to measure knowledge loaded strongly on the primary knowledge dimension, while items targeting permissive versus restrictive ideologies loaded cleanly on the attitude factor. This factor structure confirmed that factual knowledge and subjective sociosexual attitudes are psychometrically distinct constructs.

7.2. Criterion-Related and Concurrent Validity

Criterion validity was established by evaluating the relationship between ASKAS scores and observed sexual behaviors. In a multi-institutional study across 15 nursing homes involving 273 residents, White (1982a) found that ASKAS attitude and knowledge scores significantly differentiated sexually active from sexually inactive residents. Specifically, residents who reported ongoing sexual interest and activity exhibited significantly higher factual knowledge (lower knowledge scores) and significantly more permissive attitudes (lower attitude scores) than their inactive peers, confirming that the scale captures meaningful real-world behavior.

7.3. Experimental Sensitivity and Construct Responsiveness

The ASKAS has demonstrated pronounced sensitivity to educational interventions. In controlled experimental trials conducted by White and Catania (1981), three distinct populations—older adults, family members, and professional care staff—participated in structured psychoeducational programs on sexuality and aging, alongside parallel non-intervention control groups. Across all cohorts, the intervention groups demonstrated statistically significant gains in knowledge and shifts toward permissive attitudes at 4- to 6-week posttests, whereas control groups showed no significant changes. Similar pre- to post-intervention gains were independently replicated by Hammond (1979) in professional training workshops.

8. Reliability

The ASKAS exhibits strong psychometric reliability across internal consistency, split-half, and test-retest indices:

8.1. Internal Consistency

Across multiple independent validation cohorts, the ASKAS has demonstrated high Cronbach’s alpha internal consistency coefficients:

• Knowledge Subscale: Staff cohorts exhibited alpha values of .93 (n = 163) and .90 (n = 30); nursing home resident samples yielded an alpha of .91 (n = 279); community-dwelling older adults demonstrated an alpha of .92 (n = 30); and family members of older adults yielded an alpha of .90 (n = 30).
• Attitude Subscale: Staff samples demonstrated alphas of .85 (n = 163) and .87 (n = 30); community older adults achieved an alpha of .87 (n = 30); family members showed an alpha of .86 (n = 30); and institutionalized residents demonstrated an alpha of .76 (n = 279).

8.2. Split-Half Reliability

Corrected for test length using the Spearman-Brown prophecy formula, split-half reliability coefficients confirmed scale stability:

• Knowledge: .91 for nursing home staff (n = 163) and .90 for nursing home residents (n = 279).
• Attitude: .86 for nursing home staff (n = 163) and .83 for nursing home residents (n = 279).

8.3. Temporal Stability (Test-Retest)

Temporal stability assessments administered across non-intervention intervals indicated substantial reproducibility:

• Community-dwelling older adults demonstrated test-retest coefficients of r = .97 for Knowledge and r = .96 for Attitudes over a 4- to 6-week interval (n = 15).
• A combined cohort of institutional staff and family members demonstrated test-retest coefficients of r = .90 for Knowledge and r = .72 for Attitudes over comparable test-retest periods (n = 30).

9. Factor Analysis

The structural dimensionality of the ASKAS was empirically evaluated by Charles B. White (1982b) using exploratory factor analysis (EFA). The validation dataset incorporated multi-group responses (n > 500) spanning institutionalized residents, community elders, nursing staff, and adult family caregivers.

Principal components analysis with orthogonal varimax rotation yielded a distinct two-factor solution that accounted for the majority of common item variance. Factor 1 clearly represented the Attitude toward Aging Sexuality construct, with items concerning residential privacy, personal morality, masturbatory acceptance, and institutional interference loading strongly (> .40) onto this dimension. Factor 2 accounted for the Aging Sexual Knowledge construct, with items measuring physiological changes, cardiovascular risks, pharmacological influences, and lifelong continuity exhibiting primary loadings on this axis.

Subsequent psychometric investigations have affirmed the conceptual utility of this two-factor model, although some contemporary researchers investigating specific subsets (such as institutional care staff) have identified latent second-order attitude subfactors, such as Institutional Permissiveness, Familial Concern, and Personal Masturbation Acceptance. Nevertheless, the original two-factor orthogonal framework remains the standard scoring and interpretive baseline for clinical and evaluative research applications.

10. Instrument / Measurement Tool

The Aging Sexual Knowledge and Attitudes Scale (ASKAS) is structured as follows:

• Instrument Type: Dual-construct objective knowledge test and self-report attitudinal inventory.
• Administration Format: Paper-and-pencil self-report or standardized face-to-face clinical interview (frequently used for older adults with visual or motor limitations); adaptable to digital platforms.
• Target Population: Older adults (community and residential), nursing home care providers, multidisciplinary healthcare students and professionals, and adult family members of older individuals.
• Administration Time: Approximately 20 to 40 minutes.
• Item Composition: 61 items divided into:
• Knowledge Section (Items 1–35): 35 items evaluating anatomical, physiological, and psychosocial aspects of aging sexuality.
• Attitude Section (Items 36–61): 26 items evaluating moral, familial, and institutional perspectives.
• Response Scales:
• Knowledge: Trichotomous format: True, False, Don’t know.
• Attitudes: 7-point Likert-type scale: 1 (Disagree) to 7 (Agree).
• Scoring Directions:
• Knowledge Subscale: Scored such that lower scores reflect greater knowledge. Standard scoring: True = 1, False = 2, Don’t know = 3.
• Knowledge Reverse Scoring: Items 1, 10, 14, 17, 20, 30, and 31 are reverse scored such that True = 2, False = 1, Don’t know = 3. Total Knowledge score ranges from 35 to 105.
• Attitude Subscale: Scored such that lower scores reflect more permissive/supportive attitudes. Items are scored as recorded (1 to 7), with the exception of reverse-scored items.
• Attitude Reverse Scoring: Items 44, 47, 48, 50, 51, 52, 53, 54, 55, 56, and 59 are reverse scored (transformed: 8 minus raw score). Total Attitude score ranges from 26 to 182.

11. Permissions & Fee and Test Year

The Aging Sexual Knowledge and Attitudes Scale was developed and published between 1979 and 1982 by Dr. Charles B. White. The seminal psychometric validation paper appeared in the Archives of Sexual Behavior in 1982.

Licensing and Accessibility: The scale resides in the public domain for clinical, scientific, and educational research purposes. The test author explicitly designated that the ASKAS may be utilized without formal commercial licensing or royalty fees. The author requests that investigators utilizing the instrument share their empirical findings and publication citations with the author to advance cumulative research in sexual gerontology.

12. References

Atchley, R. C. (1971). Retirement and leisure participation: Continuity or crisis? The Gerontologist, 11(1_Part_1), 13–17. https://doi.org/10.1093/geront/11.1_Part_1.13

Atchley, R. C. (1989). A continuity theory of normal aging. The Gerontologist, 29(2), 183–190. https://doi.org/10.1093/geront/29.2.183

Butler, R. N. (1969). Age-ism: Another form of bigotry. The Gerontologist, 9(4_Part_1), 243–246. https://doi.org/10.1093/geront/9.4_Part_1.243

Butler, R. N. (1975). Why survive? Being old in America. Harper & Row.

Hammond, D. (1979). An exploratory study of a workshop on sex and aging [Unpublished doctoral dissertation]. University of Georgia.

Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Little, Brown and Company.

Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. Little, Brown and Company.

White, C. B. (1982a). Interest, attitudes, knowledge, and sexual history in relation to sexual behavior in the institutionalized aged. Archives of Sexual Behavior, 11(1), 11–21. https://doi.org/10.1007/BF01541362

White, C. B. (1982b). A scale for the assessment of attitudes and knowledge regarding sexuality in the aged. Archives of Sexual Behavior, 11(6), 491–502. https://doi.org/10.1007/BF01542474

White, C. B., & Catania, J. (1981). Sexual education for aged people, people who work with the aged, and families of aged people. International Journal of Aging and Human Development, 15(2), 121–138. https://doi.org/10.2190/RLL0-L407-X1FE-YVFU

13. Items of the Scale (Questionnaire)