Sexual Issues for Aging Adults
Charette A. Dersch, Steven M. Harris, Thomas Kimball, James P. Marshall, Michael A. Negretti
TexasTechUniversity
Introduction
The marked increase in life expectancy over the past century has meant that individuals over the age of 65 years form an increasingly large proportion of our population. Yet, very little attention has been paid until recently to the treatment of sexual dysfunction in older adults (Spence, 1992).
Aging adults are the fastest growing segment of the U.S. population and it is estimated that by the year 2000 that 20% of all people in the United States will be 65 or older (Comfort, 1976). With this in mind, it is unfortunate that relatively little attention has been focused on their sexual problems and concerns, and what little information is available doesn’t seem to be easily accessible.
Mary Tudor, producer of Suzi’s Loveseat, one of only a few Internet resources on sexuality and the aging says, "there isn’t much on the Web about sexuality and aging. Likewise, when I visit the bookstore, I find little specifically on that topic"(Personal Correspondence, 1998).
Who says you're too old for Sex?
Cultural attitudes that revere reproductiveness and youthful good looks may contribute to the expectation that older people are, or ought to be, asexual (Deacon, Minichiello, Plummer, 1995). Although sex roles have changed and there has been more freedom of sexual expression since the 1960s, the stereotypes that older people are physically unattractive, uninterested in sex, and incapable of achieving sexual arousal are still widely held (Hall, Selby & Vanclay, 1982).
Unfortunately, a wide variety of negative attitudes exist within society concerning sexual behavior and older people which has influenced the thinking of older people themselves, in addition to the helping professions and the general population (Spence, 1992).
The media is an important influence on attitudes in the wider community. Social and cultural definitions of sexuality and aging reflected in the mass media influence how older people perceive themselves. Education in sexuality and aging is essential for those responsible for portraying images of older people in all forms of the media (Vasil & Wass, 1993).
The constraints society imposes on older people’s sexual freedom are particularly evident in elder care institutions (Deacon, Minichiello, Plummer, 1995). Kass (1981) theorized a Geriatric Sexuality Breakdown Syndrome in our society through which elderly people internalize the negative attitudes to which they are exposed and perceive themselves as nonsexual. Kass (1981) said that this syndrome can be broken eventually by education to change society’s negative attitudes but more immediately by educating aging adults about their sexuality and helping them develop ways to cope with the negative attitudes they receive. This may be done through individual or group counseling or therapy as well as in educational settings.
Winn and Newton (1982) used Human Relations Area Files to compare the sexuality of older adults in 106 cultures. They concluded that continuance of sexuality for elderly persons in many societies indicates that cultural factors may be key determinants in their sexual behavior. Our society has generally been viewed as restricting the sexuality of older adults.
A 1983 study of nursing staff in an extended care unit still identified much staff discomfort about sexual expression among the elderly. The only sexual behaviors viewed as being acceptable were hugging and kissing on the cheek (Szasz, 1983). In contrast, graduate nursing students and freshmen medical students in two more recent studies viewed older people more positively if they were believed to be sexually active (Damrosch, 1984; Damrosch & Fishman, 1985).
Several studies have revealed the negative, ageist, and custodial attitudes of staff, particularly in nursing homes. These studies highlight the need for education for caregivers to promote attitudinal changes and, therefore, more therapeutic and holistic care to ensure the rights of older residents to sexual expression (Deacon, Minichiello, Plummer, 1995).
Older residents who display any form of sexual expression are often regarded by staff as having a behavioral problem and may even be tranquilized (Brown, 1989). Staff attitudes toward masturbation or sexual activity between unmarried residents has been reported to be disapproving and repressive, and adult children may complain of "permissive" institutional attitudes toward their parents’ sexual expression (Datan & Rodeheaver, 1983; Robinson, 1983).
Although Kaas (1978) found that staff and residents stated support for sexual expression in nursing homes, their actual behavior was less accepting. Fortunately, societal attitudes towards sexual functioning for aging adults are gradually changing. Many people who are currently classed as elderly were only middle-aged during the relatively sexually liberated era of the 1960s and 1970s, and take with them their established patterns of sexual attitudes and sexual behavior into their later years (Spence, 1992).
Who talks about Sex with Older Adults? Therapists?
Although many older people experience sexual difficulties, traditionally they have presented for treatment relatively infrequently, being more prepared to live with the problem than younger adults (Baikie, 1984; Wise, 1983). Over the past decade, however, there has been an increase in the number of elderly persons seeking treatment for sexual difficulties (Renshaw, 1983).
Leiblum and Segraves (1989) suggest that older adults experience sexual problems and concerns that aren’t that different from young people, however biological and psychological factors may need to be looked at more closely with an aging population.
The notion that sexuality is a lifelong process goes contrary to the thinking of some elderly people, their children, and health care providers (Kennedy, Haque, & Zarankow, 1997). As a result of this thinking, the topic of sexuality and the elderly is generally avoided, and when it is discussed, it is riddled with myths and misconceptions. Buying into these myths, or simply lacking an awareness of them, makes it difficult to treat, or even discuss problems of sexuality in the elderly.
Does Sex Change With Age?
For Men
Older people who lack knowledge about the normal age related changes in sexual functioning and adopt uninformed societal attitudes about sexual activity in later life can experience anxiety regarding sexual expression (Deacon, Minichiello, Plummer, 1995). Of particular relevance to older people is the fear and anxiety that may result from negative interpretation of the age-related changes in genital structures and sexual responding (Spence, 1992). However, a variety of changes in sexual responding do occur with age which need to be understood by elderly persons and the helping professions alike. For example, men tend to show increased time required to produce a full erection, an increase in the time that erections can be maintained prior to ejaculation, a decrease in the force of ejaculation, and an increase in the duration of the refractory phase (Spence, 1992).
Although the incidence of sexual dysfunction increases in old age, this is primarily related to the increased rate of health problems, rather than old age per se (Spence, 1992). Numerous endocrine, vascular, and neurological disorders may interfere in sexual function, as may many forms of medication and surgery. These health factors are more prevalent in older people and hence it is perhaps not surprising to find an increase in biologically caused sexual problems in the elderly (Spence, 1992).
Deacon, Minichiello, and Plummer (1995) indicate that the pathological factors that affect sexual function include: cardiovascular disease, diabetes mellitus, dementia, arthritis, and surgery. They also indicate that pharmacological factors play a role in sexual problems. Drugs that affect the autonomic nervous system may interfere with sexual function. Many medications that older people use, such as antihypertensives, tranquilizers, and antidepressants, can adversely affect erectile function and libido (Deacon, Minichiello, Plummer, 1995). It should be pointed out, however, that where as many drugs can adversely affect sexual function, others can enhance it (Deacon, Minichiello, Plummer, 1995).
Changes that occur in sexual physiology of an aging male can affect both erectile function and ejaculation. These changes need not have any functional impact on the subjective enjoyment of the sexual encounter. However, knowledge that these changes are not dysfunctional and assistance with the adjustment of sexual practices may be crucial in preventing dysfunction due to performance anxiety (Deacon, Minichiello, Plummer, 1995).
For Women
In older women, the physiological effects of aging on sexual function are primarily caused by decreased amounts of circulating estrogen after menopause. The rate and amount of vaginal lubrication are decreased, and there is general atrophy of vaginal tissue. For many women, these changes associated with menopause are more than offset by the freedom to explore and enjoy sexual activity without the worry of becoming pregnant (Deacon, Minichiello, Plummer, 1995).
Genital changes during this time include reduced size of clitoral, vulvar, and labial tissue, decreased size of the cervix, uterus, and ovaries, and some loss of elasticity and thinning of the vaginal wall. Some women may experience inadequate lubrication and intercourse may be painful if the vaginal walls become excessively thin (Spence, 1992). Finally, it is important to mention the cognitive decline which may occur in elderly persons and which may influence sexual activity. Cognitive deterioration relating to dementia disorders may affect sexual behavior, producing problems such as disinhibition or relationship difficulties with subsequent effects upon the couple’s sexual relationship (Spence, 1992).
Why Can’t I be Sexual?
A survey of 800 respondents’ feelings about their sexual activities revealed that older people defined and expressed their sexuality in more diffuse and varied ways than did younger cohorts, suggesting that changes in sexual expression and preferred sexual activity may be common with advancing age (Starr & Weiner, 1981).
White (1982) reviewed the literature on sex and aging and concluded that sexual behavior and attitudes in old age reflect a continuation of lifelong patterns, hence those who are most sexually active in their younger years tend to continue this pattern in their later years. Negative attitudes toward sex learned at a young age may seriously impair the ability to enjoy sex in later life (Deacon, Minichiello, Plummer, 1995). Deacon, Minichiello, and Plummer (1995) also found that sexual activity was related to sexual attitudes and behavior, level of sexual interest, and prior frequency of sexual activity. Garrison (1989) outlines other psychosocial factors which affect the sexual functioning of older people. Many older couples have to deal with problems of "sameness" and boredom with their long-term relationship, which may adversely affect the sexual relationship. A loveless relationship or marriage in the middle years can undermine a sexual experience or relationship when a later opportunity arises (Deacon, Minichiello, Plummer, 1995). Changes in lifestyle relating to retirement, and the associated role changes and adaptation problems, also need to be considered (Spence, 1992). However, conventional roles for older male cohorts emphasize the initiating, active, and performing aspects of work and social relationships. Having given up his active work role upon retirement and experiencing changes in his sexual performance, the older male may suffer some loss of self-esteem (Deacon, Minichiello, Plummer, 1995). Religious sanctions that restrict sex to the purposes of reproduction and ignore the importance of intimacy, love, and sexual pleasure for well-being deny important human needs (Deacon, Minichiello, Plummer, 1995).
A further point that needs to be discussed as a factor which influences sexual functioning in the elderly relates to opportunity. This may be affected by the availability of a sexual partner and also the living circumstances of the individual or couple (Spence, 1992). Gender differences in life expectancy may affect the sexual experiences of this population. Demographic data indicate that there are many more women than men over the age of 65. If marital status or living with a partner is a measure of "increased opportunity structures" for sex, heterosexual women have more limited opportunity for sexual expression (Deacon, Minichiello, Plummer, 1995). Decline in sexual activity for men is less likely to be due to the lack of a partner (Deacon, Minichiello, Plummer, 1995).
The lack of privacy in nursing homes is a major obstacle to sexual expression. Not surprisingly, older residents report that because of a lack of privacy and inhibiting staff attitudes, they have little opportunity to experience intimacy (Deacon, Minichiello, Plummer, 1995).
Sex Education: It’s not just for the young
Gerontological research has shown that knowledge and attitudes toward sexuality influence perceptions about sexual needs and feelings in later life. Hillman and Stricker (1994) concluded that there is generally a positive relationship between knowledge of and attitudes toward sexuality in later life.
Clearly, educational intervention is needed to dispel negative myths, stereotypes, and self-fulfilling attitudes in older people and to promote the perception that full sexual expression is part of the entire extent of adulthood. There is ample evidence to suggest that sex education for older people leads to the development of more positive attitudes. In general, however, the current cohort of older people continues to have fewer opportunities than their younger counterparts to access education, and seldom has sex education been part of the curriculum (Deacon, Minichiello, Plummer, 1995).
Starr (1985) found that sex had never been openly discussed in most senior centers visited across the United States. This seems to suggest that older adults, especially retirement home residents, need more in-depth education about their own sexuality and sexual functioning (Story, 1989). Retirement home residents and students with greater knowledge about sexuality of older adults were found to have more accepting attitudes about that sexuality (Story, 1989).
White and Catania (1982) used the Aged Sexuality Knowledge and Attitudes Scale (ASKAS) to study the effect of educational intervention on attitudes toward sexuality and aging in institutionalized older people, their families, and nursing home staff. Significant increases in knowledge, sexual activity, and satisfaction and more permissive attitudes were found after the educational intervention.
Prior to 1980, most research subjects for studies on sexuality and older adults were nursing home staff or residents, and they generally revealed limited knowledge and negative attitudes about the sexuality of elderly people (Story, 1989). Studies of human service professionals have shown that an increase in knowledge about the sexuality of older adults is accompanied by a trend toward more accepting attitudes on the issues (Story, 1989).
Education in the field of sexuality and aging is also essential for all health professionals who are in contact with older people, both in institutions and in the wider community. Many types of professionals are involved in the provision of health services to older people, and all of them need to be aware of including sexuality in the promotion of mental and physical health in older adults (Deacon, Minichiello, Plummer, 1995). Increased knowledge about elderly sexuality appears to be a good way to develop more positive attitudes on the topic. Greater knowledge and acceptance of older adult sexuality and sexual functioning are important goals for all sex educators, counselors, and therapists trying to meet the needs of older adults (Story, 1989).
senior-site.com
"Senior-Site" offers relevant information for seniors on a number of topics. Information can be accessed through the site map located on the home page. A list of relevant topics for seniors is listed including an area devoted to sex and senior citizens. Sexual topics include sexually transmitted diseases, impotence, "good" sex, sex over 50, contraceptives, and reflections on sex. The site is user friendly and the information contained within each topic area is accessible and potentially useful to both older adults as well as health and human service providers. The information appears relevant and well researched but the site offers no references, contains only brief information, and is not maintained by an expert in the field.
Both of these sites ("Sexuality in Older Adults" and "Sexuality in Later Life" respectively) contain the same information presented by The National Institute on Aging (NIA). The NIA is a branch of the National Institute of Health (NIH) that conducts biomedical research for the United States government. The article gives statements regarding sexuality in later life concerning normal physical changes with age, effects of illness and disability, emotional concerns, and other issues including AIDS, medicine, and masturbation. The sites are user friendly and the information can be read in only a few minutes. Both sites lack complete information but may be a good start to introduce the issues of sexuality and aging to health professionals and clients alike.
This site, "The Human Sexuality Web" is maintained by counseling psychology graduate students at the University of Missouri, Kansas City. The information is brief but informative. The site covers physical changes in the aging male and female, effects of some common medications, and other sexual health issues. Unlike other sites, this site contains information about social issues and other influences that impact the sexuality of aging adults. Additional information at this site offers suggestions on how to cope with changes in body and mind as one ages. Finally, a list of additional high quality references are provided for future reading. The information is presented in a clear format and is easy to navigate.
"The Virtual Medical Center" is a general medical site that offers information addressing general senior health issues. Areas of interest can be accessed through the site’s own search engine. Site visitors can highlight topic areas (i.e., senior health) and enter appropriate key words. Search results present articles by medical experts as well as conference highlights, educational materials, drug information, medical news, and support groups. The site contains articles on sexuality and aging in a number of areas including impotence, biological changes, sex after surgery, sex with a disability, and sex and chronic illness. The site also presents general health products for sale (i.e., books, videotapes, vitamins, dietary supplements). Although this site offers excellent information on sexuality and other medical topics for an aging population, we are concerned that the site’s search function generates some information from peer reviewed research publications. This may prevent accessibility to information due to the highly jargonized writing sometimes found in scholarly journals.