Introduction

Sexuality is an important part of health and quality of life at all ages and thus is an important area for health-care providers to address. As the baby boom generation ages, different attitudes and mores regarding sexuality are coming forward as a result of growing up in the “free love” generation. In time, discussion of sexuality with older adults is anticipated to be more direct, open, and often initiated by well-informed patients. Now, however, a number of fallacies regarding sexuality later in life prevail. Many prefer to believe that sexuality in older adults simply does not exist. Brogan notes that “there is a general societal belief that old people are, or should be, asexual and a false assumption exists that physical attractiveness depends on youth and beauty.”[1] Alternatively, sexuality in older adults is considered a laughing matter. Comical cards and ones on old age often give messages about physical weakness and failures in sexual performance.[2] Misinformation and misperceptions about sexuality and older adults are held by both patients and clinicians. Failure to adequately address sexuality and diagnose and treat sexual problems can lead to depression and social withdrawal,[3] self-discontinuation of those medications with adverse side effects to sexual satisfaction,[4] and increased risk for sexually transmitted infections including HIV/AIDS.[5]

Sexual activity

The number of years of potential sexual activity in later life is increasing.[6] The demographic trends of Americans living longer, with increasing active life expectancy, and smaller families, allows many older adults greater privacy to engage in sexual activity. Data on sexual activity of older Americans, available from three studies, reveals and reinforces some consistent trends. In 2009 the AARP surveyed 1,670 people 45 years and older.[7] The National Survey of Sexual Health and Behavior, conducted in 2009, included 14- to 94-year-olds with 1,008 people over age 50.[8] From 2005–2006, the National Social Life, Health and Aging Project (NSHAP) surveyed 3,005 Americans 57–85 years old.[9] In all three studies, across all age groups, sexuality was more important to men than women. Men had more frequent sexual thoughts, feelings of sexual desire, and engagement in self-stimulation than women.[7–9] Adults with partners were much more likely than those without partners to engage in interpersonal sexual activities such as kissing, hugging, oral sex, and intercourse.[7, 9, 10] Adults with partners expressed more importance to having a satisfying sexual relationship, more frequent sexual intercourse, and more sexual satisfaction overall.[7, 9, 11]

Although they represent 5%–10% of the older adult population, there is very little known about the sexuality of the lesbian, gay, bisexual, and transgender (LGBT) population. In 2011, the Institute of Medicine issued a report calling for more research on the LGBT population with an increased focus on LGBT elders, racial and ethnic subpopulations, and bisexual and transgender people.[12] Today’s older adults grew up in an environment much less supportive of diversity. Examples include creation of an official diagnosis in 1952 of homosexuality as a sociopathic personality disturbance and Senator McCarthy including gay men and lesbians on his blacklist. In 1973 the American Psychiatric Association removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders.[12] The Still Out, Still Aging MetLife Study conducted in 2010 surveyed 1,201 LGBT people aged 45–64 and found the extent of disclosure of sexual orientation and/or gender identity varied significantly. Whereas 74% of gay men and 79% of lesbians were completely or mostly out, this applied to only 39% of transgender and 16% of bisexual people. Moreover, LGBT respondents indicated that health-care providers are among the groups to whom they have not come out.[13]

Both physical and emotional aspects to sexuality and the desire for intimacy continue throughout life.[11] Physical closeness can be expressed in many ways including holding hands, hugging, kissing, mutual stroking, masturbating, oral sex, and intercourse. Studies have shown that for older adults the current level of activity correlates with past sexual frequency, and most older adults desire more activity than what they have.[14] Lack of partners and lack of privacy are significant obstacles for sexual expression. Adults living in age-segregated environments, such as retirement communities, express more interest in sexual activity and engage in sexual activity more often than their cohorts who are not age-segregated.[10] Some older adults report that sex became more pleasurable and of greater importance with age.[11]

In the National Survey of Behavior and Health, the incidence of vaginal intercourse declined from 51% of women aged 50–59 to 22% of women over 70 years primarily as a result of the loss of a male partner.[8] Avis examined the impact of age and gender on sexual function and found that older women reported a cessation of sexual relations due to the death of a spouse (36%), illness of a spouse (20%), or a spouse’s inability to perform sexually (18%). Only 10% of the older women reported a cessation of sexual activity due to their own illness, loss of interest, or inability to perform.[15] Szwabo noted that as roles change within a relationship, so can the sexual behaviors of the couple. If the wife has assumed the caregiver “nursing” role, it may make sexual feelings and expressions less intense as the spouse may be seen as a patient rather than a sexual partner.[16] Adults of both genders without partners appear to adjust their sexual expectations and priorities. In one study it was noted that most people reporting no importance of sex were found to have no current partner and no anticipation of a partner in their lifetime.[11]

NSHAP revealed that the decline in sexual activity with age is largely mitigated by partner availability. The prevalence of sexual activity declined with age from 73% among those 57–64 years old, to 26% among those 75–85 years old. However, for older adults who still had a partner, sexual activity remained prevalent with 65% of those aged 57–64 and 54% of those aged 75–85 having sexual activity at least two to three times per month. Among those who were sexually active, about half of both women and men reported at least one bothersome sexual problem. Yet only 22% of women and 38% of men reported having discussed sex with a physician since the age of 50.[9]

Barriers to treatment

Several barriers to seeking treatment for sexual problems were revealed in an interview study of 45 adults aged 50–92 years old.[17] Patients expressed a preference to consult a general practitioner of similar age and gender with the goal of minimizing embarrassment by discussing concerns with someone likely to have had similar experiences. Patient perceptions of providers’ attitudes limited interactions if perceptions existed that older people are or should be asexual or access to treatments involve age-based rationing. In this study, 97% said they would discuss sexuality if the provider brought it up, and 80% stated a willingness to return for a designated sexual concerns appointment.

Both providers and patients may mistakenly attribute sexual problems to “normal aging,” and both may lack knowledge about services and resources. As with many potentially sensitive issues it appears that patients are waiting for their physicians to raise the topic.

Sexual response cycle and common disorders

The traditional model of the human sexual response cycle has four phases described in a linear progression.[18] The first phase, desire, involves the brain and one’s interest in or urge for sexual activity. The second phase, arousal, involves the vascular system and the body’s response to stimulation. In men this is primarily recognized by penile erection, and in women by vaginal lubrication and genital engorgement. The peak of arousal is referred to as plateau. The third phase, orgasm, involves the spinal cord and perineal musculature. In this phase the body experiences involuntary contractions of the pelvic muscles and reproductive organs, and men experience ejaculation of seminal fluid. In the fourth phase, resolution, the body recovers from orgasm with a physiological rest period. Recent studies reveal greater variability, flexibility, and a more circular nature to sexual response. In both genders the relationship between desire and arousal is complex with variable order and overlap; the motivations for sex are multiple.[18] The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has adjusted criteria for diagnosing sexual dysfunctions. It has combined desire and arousal disorders in women into one classification, and created separate diagnostic classifications for men and women.[19]

In 1966 Masters and Johnson’s landmark study of older sexuality noted that natural aging leads to a need for more time to engage in sexual activities. Advancing age is associated with delayed arousal and a greater need for genital stimulation, reduced penile rigidity and vaginal lubrication, loss of the sensation of ejaculatory inevitability, and increasing anorgasmia.[20]

Tables 45.1 and 45.2 outline gender-specific sexual response cycle markers, changes with aging, and common disorders for men and women.[6, 9, 18] Whereas women experience menopause and its impact on sexuality over a relatively short period of time, men’s physiologic changes are thought to occur over a longer period of time with less awareness as change is occurring. The physiological changes associated with age alone are an insufficient cause to cease sexual activity, and for some these changes are felt to enhance sexual activity.

Misconceptions regarding sexually transmitted infections

Since sexually transmitted infections (STIs) are primarily a health issue of young people, there is very limited information on this topic in the older population. Lacking research, it is unclear if STIs are increasing in the older population or if the increased numbers merely reflect the rapidly expanding population in general. There are several issues that increase the potential for older adults to acquire STIs. Longer, more active living combined with increased rates of divorce augments the number of new sexual partners.[21] Age-related changes in the immune system may increase susceptibility to HIV infection.[22] Postmenopausal women are more susceptible to the transmission of the HIV virus because of atrophic changes in the vaginal mucosa leading to microabrasions as a result of intercourse.[21, 22] For older adults, negotiating safer sex may be unfamiliar and challenging, they lack knowledge to identify HIV/AIDS risk factors, and they are less likely to use condoms.[5, 21, 22] Public health promotion materials regarding STIs fail to adequately target older adults.[5, 21] Health-care providers lack awareness of seniors’ sexuality, fail to engage in conversations about risks, and are less likely to test for the virus.[5, 21, 23]

Until recently, many national health agencies provided stratified STI and HIV data only up to ages 45 to 49.[21] In 2005, people over age 50 accounted for 15% of new HIV/AIDS diagnoses, 24% of those living with HIV/AIDS, and 35% of AIDS deaths.[24] It is estimated that by 2015, 50% of the HIV population in America will be 50+ years old.[21, 22] In the 1980s, the primary route of HIV transmission in older adults was contaminated blood because older adults have higher rates of medical procedures. With routine testing of the blood supply, sexual intercourse and needle sharing are now the main sources of HIV infection.[5] In recognition of the increasing prevalence of HIV, the Center for Disease Control and Prevention issued a guideline in September 2006 advocating that “in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13–64 years. Older adults who are at increased risk should also be screened.”[25] The US Preventive Services Task Force April 2013 guideline concurs with this screening as a grade A recommendation, indicating there is high certainty that the net benefit is substantial.[26]

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