Aging and Sex
From Encyclopedia of Sex and Sexuality
There are two common misconceptions about sexual activity later in life: both are harmful to individuals who accept them. The first—that sexual interest and activity dwindles and eventually ceases between ages sixty and seventy—should seem a misconception to any energetic person of this age, but coming amid other messages of decline, it can subtly undermine an individual’s determination to continue a full life. It can be even more destructive for those living with younger persons, who find their elders’ sexual interests inappropriate, or for older people living in group or nursing facilities, where their personal freedoms and activities are restricted. The second misconception—that all older people can have active and wonderful sex lives well into their nineties—is harmful because it does not account for the physical, social, and psychological problems that increase with age and impair sexual activity in many older people.
What then is the reality of sex for most people as they age? Most people with an available partner and reasonable personal health can continue to enjoy sexual relations into their eighties and some even into their nineties. The single most important factor in their sex lives is then the availability of sex partners, within or outside marriage. About half of men over sixty-five are married, but differences in men’s and women’s life expectancies means that many married women will face eight to ten years of widowhood. The reluctance of many older widows and widowers to begin new marriages has led them to cohabit or begin affairs the way the young do today. But the demographic facts are cruel for women: the ratio of men to women aged sixty-five to seventy-four is 100 to 131; for those aged seventy-five to eighty-four it drops to 100 to 180; and for those over age eighty-five it falls to 100 men to 229 women.
The question of general health also has an impact on older people’s sexual lives. Although it is estimated that 80 percent of Americans over the age of sixty-five have some chronic health problem that can potentially affect their sexual functioning, most report having a healthy interest in sex. The single most sexually debilitating disease in older people is diabetes; half of diabetics experience some loss of sexual function—erection difficulties among the men and loss of vaginal responsiveness among the women. In addition, many medications taken by the elderly, especially tranquilizers, sedatives, antidepressants, and blood pressure medicines, have a negative effect on sex functions (indeed, for older men, the use of medications is the most frequent cause of difficulty with erections). Finally, the “substances” that some individuals may have used when they were younger—among them tobacco, excessive alcohol or caffeine, marijuana, and cocaine—can be extremely debilitating to sexual activity as one ages.
Aging does bring changes in sexual activity—as it does to other life activities—even when men and women are in good health and have sexual partners. By the age of fifty most men will notice a slower and reduced intensity of sexual responses. According to a survey known as the Duke Longitudinal Study, 75 percent of all men interviewed in their sixties still engaged in sexual intercourse at least monthly. Over the age of eighty, 50 percent of men were interested in sex, but only 10 percent still engaged in sexual intercourse. The Duke study reported that 39 percent of women between the ages of sixty-one and sixty-five were sexually active, as were 27 percent of those aged sixty-six to seventy-one. Only 10 percent of the men between sixty-six and seventy-one, but 50 percent of the women over sixty-five, expressed no desire or interest in sex. It is clear from this that there is a wide range of sexuality in people as they age.
In a recent study of healthy upper middle class people between the ages of 80 and 102 in a residential retirement facility, the most common sexual activities reported were touching and caressing. Masturbation and sexual intercourse occurred less frequently. Eighty-eight percent of the men and 71 percent of the women interviewed fantasized about sex, but the frequency of sexual activity did not change significantly after the age of eighty.
In men the libido, or sex drive, is largely due to the male hormone testosterone. This hormone reaches its highest level at approximately age nineteen and men will experience a gradual decline in the level of testosterone for the rest of their lives. Testosterone, as well as intact blood vessels and nerves, is a factor in the ability to obtain an erection. Beyond the ages sixty to seventy, as many as one-third of all men have testosterone levels low enough to lose the ability to achieve and maintain an erection. Furthermore, the time needed to achieve orgasm lengthens with age, the orgasm itself decreases in intensity, and there is less ejaculate. Finally, the refractory period (the interval required between erections) increases. In very elderly men, particularly those over ninety, it may be weeks before the man is able to ejaculate again.
In women similar changes occur with age. Their libido is also controlled by the male hormone testosterone but the lubrication of the vagina is partially controlled by the female hormones, mainly estrogen (and also by intact blood vessels and nerves). Therefore, as women age, it becomes more difficult to lubricate the vagina, the plateau period increases, and orgasm becomes less intense. Because of the increase in the refractory period, multiple orgasms also decrease with age in women.
Complaints by older people about their sexuality can be explained in part by changes in their bodies. In women, the most common complaints are vaginal dryness and atrophy, coital pain, a less tight yet constricted vagina, and sagging breasts. These changes have an adverse effect on both sexual performance and self-image. In men, the most common complaints include delayed and partial erection; prolonged plateau; reduced ejaculatory time, fluid force, and contraction; a decreased ejaculatory inevitability sensation; ejaculation with a flaccid penis; rapid penile softening; and longer refractory periods.
Many elderly people of both sexes suffer from psychological causes of sexual dysfunction. They may expect to perform sexually at age seventy as they did at age twenty, which is clearly impossible. Common psychological causes for sexual dysfunction in later life also include a loss of positive body image (exacerbated by physical disease); emotional stresses, tensions, and conflicts; interpersonal conflicts; and cumulative losses of a financial or personal nature.
 Treating Sexual Problems of Older People
Very few patients of any age actually volunteer sexual information to their physicians and very few physicians ask. Clearly, if people want to discuss problems of sexuality, it is necessary to initiate communication with their physicians.
Almost any physical illness, especially those likely to be encountered by older people, can be associated with sexual dysfunction. With any change in sexual function, therefore, the first rule is to be sure that it is not a symptom of some illness. It is also important to be sure that medication is not causing the sexual dysfunction, since some of the most commonly used drugs, both prescribed and over-the-counter, can cause sexual dysfunction. Only by discussing the problem with a physician can the patient potentially be switched to another drug. In addition, over-the-counter medications such as non-steroidal and anti-inflammatory agents and substances such as cigarettes or coffee are often unsuspected and not reported to the physician.
Some older men with erectile dysfunction may need injections of testosterone. Others will benefit from negative-pressure devices that pump up the penis to achieve an erection. Rarely is a penile implant necessary (see Impotence).
Estrogen replacement therapy for women will often help to achieve lubrication of the vagina. It is important to realize that hormone therapy may take up to two years to be effective, but the use of water-based lubricants can also be helpful. For women with depressed libido, treatment with testosterone is useful.
Other recommendations for both men and women encountering sexual difficulties due to normal aging include rest prior to sexual activity, improved nutrition, improved personal appearance, and the use of sexually provocative clothing. The couple should discuss changes in their sexual function such as the longer time needed to achieve orgasm. Many older couples have been having sexual relations in the exact same way for forty or more years and may benefit from changes in sexual position and techniques: oral-genital love-making may awaken sexual interest.
If physical illness is causing sexual dysfunction, it must certainly be treated. Not all illnesses are curable, however, and sometimes medication cannot be stopped. In theses instances it is very important to introduce changes in sexual practices. For example, for people with arthritis, a side-to-side position may be more comfortable: if the leg is in pain, a pillow placed under it may relieve discomfort. A hot bath prior to intercourse can help relax muscles and joints. If the man has had a heart attack, the woman can straddle him in the superior position or with rear entry to make sex easier for him. If there has been surgery, any pressure on painful areas must be avoided. With any illness, there must be an emphasis on sensual, affectionate, and nongenital foreplay. The key to continued sexual activity is for the couple to discuss with each other what is most pleasurable.
Psychological problems can cause sexual difficulties at any age. Depression is common in the elderly and must always be considered. Body image can be improved by exercise, recreation, and relaxation. Social contacts must be encouraged, particularly if one wants to meet people.
While counseling can help older people, all too often they are denied psychological help because of their age. This is “ageism,” because studies have shown repeatedly that psychotherapy and counseling are effective at any age.
As people age, they all too often forget the role of romance in their relationships. The courtship aspects of sexuality are important at any age, but probably more so with advancing age. Typical counseling techniques include the awareness of fantasy; reduction of guilt and anxiety; acceptance of direct stimulation of the genitals (including masturbatory techniques and mechanical aids); techniques to enhance self-esteem regarding one’s sexual attractiveness; and acceptance of age-related changes in function.