The majority of studies on sex and aging confirm that most individuals in later life retain sexual interest and ability. Results
of earlier studies indicate that many men and women remain sexually active well into their 70s.1,2 Recent surveys by AARP3,4 confirm these earlier findings.
Although sexual activity is potentially life-long, often medications, illnesses, partner availability, and relationship problems,
more than age-related changes in sexual responsiveness, can be responsible for discontinuation of sexual activity. Clinicians
can help older patients adapt to these changes and maintain maximal sexual health. With intact health, aging patients' sexual
functioning can be preserved until the end of life.
Sexual health communication
With aging women. Sexual concerns are common among women across the lifecycle, including as they age.5,6 When confronted with these and other issues, women are more likely than men to seek health care. Based on their sense of
the clinician's willingness to discuss sexual health issues, female patients will disclose their sexual concerns.5,6
Regardless of age group, women find it easier to discuss sexual concerns if the primary care clinician initiates the conversation.
Although often embarrassed to raise the topic, female patients report that a sense of concern, caring, and continuity in their
relationship with the clinician facilitates the discussion. This appears true whether the woman is seeing a male or female
physician. Even women who have been exposed to abuse report these provider qualities as facilitating sexual health discussions.7
Communication difficulties may arise if the clinician seems rushed or embarrassed by the topic, an age difference exists between
the female patient and provider, or the woman has experienced abuse.7
Patients of both genders also may be fearful that the clinician will consider their concerns as inappropriate for their age,
may believe their concerns are psychosomatic in nature, or may fear there will be no treatment to resolve the problem. All
these barriers to sexual health discussion are reduced when clinicians raise the topic, are empathic in manner, and/or facilitate
a follow-up session dedicated to the topics.
With aging men. Men are often hesitant to discuss sexual problems with their clinicians. Men consult family physicians for health-related
problems less frequently than do women, thereby reducing the opportunity for disease recognition and treatment.8 Consequently, men receive fewer medical services, less health information, and are less likely to receive advice about how
changes in behavior can improve health from their clinicians.9 Emphasis is on common cardiovascular risk diseases, including hypertension, heart disease, and diabetes mellitus, while ignoring
conditions that determine the patient's quality of life.10 Research on why men do not make appointments with family doctors revealed several key themes:11- support seeking,
- help seeking, and
- barriers.
The research supports the strong role played by the female partner in determining health-seeking behavior. Men tend to seek
support indirectly, and often from their female partners, rather than male friends. Their help seeking is influenced by perceived
vulnerability, fear, and denial and help is sought for a specific problem rather than general health concerns.
At an office visit, men often do not report complaints to the clinician, and instead wait for the clinician to find out why
they are really there. Men's perception of health may be viewed as a resource that enables the completion of daily activities.12 Therefore, men concentrate on the purpose of being healthy rather than being healthy for the sake of good health.
David Sandman, co-author, the Commonwealth Study, said, "Physicians can be more attuned to the special health concerns of
their male patients and be more proactive in initiating communication."13
If clinicians start by asking the patient general questions about sexual activity and interest, and relate this to healthy
"masculine" intimacy, the clinician may get a more honest answer than by directly asking about sexual function. Sense of immunity
and immortality, difficulty giving up control, clarifying reasons for seeking care, belief that seeking is unacceptable, and
system constraints, such as time and access, can create barriers to help-seeking behavior in men. Older age cohorts may be
even more rigid in these beliefs.
With modern aging adults. Addressing sexual health requires an expanded view of sexuality. Such a view emphasizes the importance of understanding individuals
within the context of their lives and defining sexual health across physical, intellectual, emotional, interpersonal, environmental,
and spiritual aspects of their lives. It also requires that clinicians be aware of the cultural views of patients and their
sexual orientation. This is particularly true as the Baby Boomer generation ages.
The sexual behaviors and interests of aging Baby Boomers are beginning to emerge through surveys, such as those conducted
by AARP.3,4 Although Boomers are products of the "free love generation," they appear to hold traditional values regarding extramarital
relationships. They do, however, appear more willing to experiment with new activities, such as watching pornography with
their partners and trying new sexual positions.
When addressing the aging Boomers, another variable to consider is the growing population of divorced and single adults engaged
in sexual relationships, who may be at risk for sexually-transmitted infections, including human immunodeficiency virus (HIV).
Clinicians should initiate a discussion of safe sexual practices and condom use with their aging patients. This is especially
true for the current cohort of seniors who may be unfamiliar with condom use and unaware of the risks associated with unprotected
sex. Health care providers can address this topic by telling the patient: "In this era of HIV and other sexually transmitted
diseases I now ask all my patients about sexual practices and concerns. Are there any questions I can answer for you?"
Seniors may also participate in self-pleasuring activities. For some, this may be a life-long pattern, while for others it
may be an adjustment to not having a partner or having a partner who is no longer capable of engaging in sexual activities.
Age, illness, and the sexual response cycle
Table 1. Substances, illnesses affecting sexual response
|
Understanding the phases of the sexual response cycle and the effect of chronic illnesses and medical and/or surgical interventions
will help the clinician suggest changes to maximize a patient's sexual health. Table 1 presents substances and illnesses that
may have a negative effect on the various systems of the sexual response cycle.
The sexual response cycle includes desire, arousal, plateau (the peak of arousal), orgasm, and resolution phases. The process
of aging can dampen sexual functioning and make functioning more susceptible to negative consequences from chronic illness
and medical interventions.14
A 'use it or lose it' phenomenon exists for both genders. Less sexual activity tends to contribute to decreased interest and
a diminished sexual response. It may also contribute to a decline in the overall sense of well-being.
Older adults who reside in assisted living facilities or extended care facilities face additional challenges regarding sexual
expression. Issues of privacy, attitudes and behaviors of families and staff, as well as decline in physical and cognitive
abilities can contribute to a discontinuation of sexual behaviors. Additional dilemmas occur when individuals have dementia
and are potentially incapable of consenting to sexual activity engagement. Despite prevailing myths of hypersexuality among
individuals with dementia, studies show that relatively few (7% to 17%) patients display inappropriate and/or unwanted sexual
behaviors.15 These studies, however, often include behaviors, such as undressing, that may be a sign of disorientation and not a sexual
act.16
Desire phase. Various environmental, psychosocial, cultural, and physiologic processes can influence desire. Physiologic desire requires
functioning neurotransmitters, androgens, and an intact sensory system. In men and women, sexual desire is linked to levels
of androgen, testosterone, and DHEAS. In men, testosterone levels begin to decline in the fifth decade and continue steadily
throughout later life.17 For both genders, DHEA levels begin to decline in the 30s, steadily thereafter, and are quite low by age 60.18
The effect of aging on sexual desire varies greatly from person to person, depending on such factors as general and mental
health and the state of the relationship. Desire may be indirectly affected by changes in the sensory system, such as decreased
smell or taste, which can occur with aging, or changes in skin sensation. Androgen deficiency can decrease genital and breast
sensitivity.
Illnesses and/or medications used to treat illness can negatively affect desire phase by lowering relative androgen levels,
raising SHBG, or interfering with endocrine and neurotransmitter functioning. Examples include exogenous hormones (eg, estrogens,
progesterones), diabetes, and depression.
Arousal and plateau phases. Combined with desire, these two phases require an intact parasympathetic nervous system and vascular system. Increasing blood
flow to the genitals leads to vaginal lubrication and penile erections.
Diminished estrogen in postmenopausal women can lead to a diminution of lubrication and a reduction in sexual responsivity.
Estrogen supplementation may enhance sexual functioning by restoring the integrity of vaginal tissue, but it can also inhibit
sexual functioning by reducing levels of free testosterone.
Age-related changes in peripheral nerves, blood vessels, and muscle tissue may also affect sexual functioning in men and women.14 For example, as men age, penile sensitivity is reduced. Having and maintaining erections can require more intense and continuous
direct physical stimulation, and erections may not be as firm as earlier in life.
The rate of erectile dysfunction among men aged 65 and older is 15% to 25%.19 These figures would be higher if men with mild cases were included. The Massachusetts Male Aging Study found that 52% of
men (age 40-70) had some degree of erectile dysfunction.20 Since erectile dysfunction is higher for men who smoke and drink alcohol to excess, educating male and female patients about
these risk factors is vital.
Orgasm. Older women remain capable of multiple orgasms. Boomers may fatigue sooner than when they were younger, sensation may be
lessened because of decreased muscle tone, and orgasm may require a longer duration of direct physical stimulation.
For men, the force and volume of ejaculation may diminish and ejaculation may not occur with every sexual encounter. Ejaculatory
difficulties include rapid, delayed and retrograde ejaculation. Difficulties with rapid ejaculation tend to lessen with increasing
age while delayed orgasm may worsen. Medications, such as selective serotonin reuptake inhibitors, can exacerbate delayed
ejaculation. Retrograde ejaculation, a condition in which the ejaculate is propelled into the bladder, can result from medication
side effects or after surgery in which the sympathetic nerves have been damaged, such as transurethral prostatectomy.
Resolution phase. For men and women, resolution to pre-excitement phase occurs more rapidly with age, although this occurrence is most apparent
in older men. Following orgasm, detumescence occurs rapidly, and the refractory period, or the amount of time that must pass
before a man is capable of another ejaculation, significantly increases with increasing age.
Sexual health inquiry and evaluation
Table 2. A general approach to evaluating sexual health concerns
|
Clinicians should obtain a broad history, which accounts for not only the sexual concerns, but also relationship and life-events.
Health care maintenance visits are ideal for such inquiries (table 2).
Given time constraints in primary care settings, it is important for the physician to acknowledge the sexual concerns and
set a follow-up appointment for the discussion. Open-ended questions help elucidate the onset, course over time, and factors
that improve or worsen symptoms. Compassionate honesty and use of 'normalizing' statements can be helpful. For example, "It
is common for women who have had a mastectomy to feel differently about their bodies and to notice changes in their interest
in sexual activity." Or, "This is an important topic. Let me check into this, and we'll set a follow-up appointment to delve
into the matter."
The clinician should maintain a nonjudgmental attitude and clearly convey that it is normal and desirable to have sex in the
later years. However, it is important not to give the impression that remaining sexually active is essential to maintaining
quality of life, if a couple has made a deliberate choice not to remain sexually active. It is helpful for clinicians to be
comfortable discussing the sexual response cycle and sexual functioning as it relates to aging. Good communications skills
and a nonjudgmental approach are essential in increasing both the clinician's and the patient's comfort. It is also helpful
to begin with basic questions such as, "Are you sexually active?" The physician can gradually build to the potentially more
difficult questions (ie, "How does your illness affect your sexual function?") Clinicians can be aided in this process by
compiling pertinent patient education handouts and using them as a basis for discussion with their patients. When discussing
sexuality with patients, assumptions should be avoided, particularly regarding sexual practices, preferences, and orientation.
The clinician should be prepared to address topics, such as masturbation, sexual fantasies and thoughts, types of sexual behaviors
the patient engages in regularly, and the number of sexual partners and risks for sexually-transmitted infections.
Older gay and lesbian patients may be reticent to disclose their sexual orientation. These patients grew up before the gay
liberation movement and in an environment that was, at times, openly hostile.16 Older gay men may also be reluctant to discuss their sexuality because of the negative association of being gay with having
HIV.21 The clinician who maintains a nonjudgmental and accepting stance can increase the comfort level of the patient in discussing
sexual identity issues. Also, the use of gender neutral terms, such as "partner," may foster open communication between the
provider and the patient.22
There is a paucity of research regarding the needs and interests of such sexual minority patients, especially older lesbians
and transgendered individuals. Available studies generally have relied upon healthier and better- educated participants, thus
skewing the perspectives of this population. Harrison's study of older lesbians22 found a higher incidence of various cancers, including breast, lung, and ovarian cancer, as well as lifestyle issues (eg,
smoking, alcohol use) than has been seen in other studies.
Therapeutic overview
Table 3. Basic sexual counseling for older men and women
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Older patients who have functioned well in the past but are having difficulty adjusting to age-related physical changes often
respond well to educational-oriented counseling with a health care provider (table 3).
Patients without partners can benefit from medical and psychotherapeutic interventions that promote solitary sexual activity.
It is critical to keep in mind the impact that psychological conflict and/or relationship issues can have on sexual health.14 Relationship issues are a major contributor for the decline in sexual activity of older individuals.23 Lifelong psychological conflicts may heighten as people age. For example, as men grow older, they often become more dependent
on their wives with respect to their ability to function sexually.2
Couples may misunderstand normal age-related changes, which can exacerbate psychological insecurities. Intrapsychic and/or
interpersonal sexual difficulties are best treated with psychotherapy after any physical causes have been addressed. Sexual
difficulties can begin as minor changes and escalate into more complex difficulties if sexual health is not addressed at an
early stage. For example, a woman may become less sexually responsive because of declining levels of hormones and reduced
lubrication. The couple may not be comfortable discussing these changes. Her male partner may equate her decreased interest
with her level of interest in him and develop erectile difficulties. If he subsequently stops initiating sexual activity,
she may feel rejected. A subtle age-related change can potentially lead to abstinence, diminished quality of life, depression,
and/or extra-relationship affairs or separation.
Asking sexual partners about each other's sexual function can be useful. Women ranked "partner sexual difficulties" as a common
sexual concern.5,6 Relationships have a profound effect on sexual health and talking with the partner can potentially enhance resolution of
the problem.
Sexual difficulties can lead to feelings of failure and loss of self-esteem. These feelings may be compounded by a partner's
reaction of disappointment or anger. Referral to a psychotherapist trained in sexual therapy can be helpful for interested
couples.
Supplemental testosterone has been shown to improve libido in older men with low testosterone levels.24 A causal relationship between risk of prostate cancer with testosterone supplementation has not been demonstrated.25 Men treated with testosterone who were studied retrospectively did not show evidence of an increased risk of prostate cancer.26
Men and women who struggle with arousal difficulties can also lose interest in sexual activity desire. This loss may occur
with a specific partner or it may be generalized. Life stressors can either begin or worsen at midlife. Issues such as retirement,
diminished income, divorce, unresolved anger, death of friends and family, and illnesses requiring therapeutic intervention
can all lead to diminished sexual desire and sexual difficulties.
Although estrogen, with or without progesterone, is effective in reversing some menopausal symptoms, it often does not restore
sexual functioning for women. Women most likely to respond to testosterone supplementation have low free testosterone levels
and/or their total testosterone to sex hormone-binding globulins (SHBG) levels ratio is low secondary to elevated SHBG levels.27 Symptoms of androgen deficiency include diminished sexual desire and fantasies, reduced sensitivity to sexual stimulation,
and decreased sensation of arousal and orgasm. Women who receive supplemental estrogen and testosterone after a total hysterectomy
can have greater libido than those given estrogen alone or a placebo.28 Additionally, some women respond to sildenafil with heightened arousal and lubrication and increased blood flow to the vagina
and clitoris.
Table 4. Therapeutic approaches to arousal difficulties
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Table 4 presents a general overview of therapeutic approaches to arousal difficulties (a detailed discussion of these is outside
the scope of this article). Generally, the goal is to increase blood flow to the genitals. Furthermore, therapeutic measures
that enhance sexual interest and desire will augment arousal, as positive sensations resulting from enhanced blood flow to
the genitals within the context of a positive relationship will have a positive feedback loop for desire. Desire and arousal
synergistically and mutually enhanced.
Various therapeutic options to treat ejaculatory difficulties have included behavioral techniques, antidepressant medications
(eg, paroxetine, sertraline, fluoxetine), topical anesthetics agents (eg, lidocaine, SS-Cream), PDE5 inhibitors, and combinations
of these approaches.29
Conclusion
Patients appreciate knowing that clinicians are concerned about sexual health and open to discussing these issues. Chronic
illnesses along with pharmacologic and surgical interventions are more likely to interfere with sexual functioning than aging
alone. The 'Baby Boomer' generation is likely to have higher expectations from clinicians in regard to sexual health. A non-judgmental
approach, understanding various physiological and psychosocial affects on the sexual response cycle, and basic counseling
and therapeutic techniques can prepare clinicians to address the sexual health care needs of aging patients.
Dr. Nusbaum is professor, department of family medicine, University of North Carolina, Chapel Hill, NC.
Ms. Lenahan is associate professor, department of family medicine, University of California, Irvine, in Orange, CA.
Dr. Sadovsky is associate professor of family medicine, SUNY-Downstate Medical Center, Brooklyn, NY.
Disclosures: The authors have no real or apparent conflicts of interest with the subject under discussion.
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