Sexuality in Old Age

Carien G. Hartmans

Introduction

Sexuality, sexual behavior, and intimacy are considered aspects of quality of life and remain important throughout all phases of life. Sexuality is also associated with physical health, which makes it even more important to understand and address sexual function in late life.¹ However, knowledge and attitudes about sexuality in older adults is still limited.²^,³ Most studies focus on frequency of sexual activity and report a decrease in older adults.⁴ Furthermore, there is no unified definition of sexuality in later life, making it difficult to interpret or compare the available data. Studies that use a broad definition of sexuality and sexual behavior indicate how a percentage of older adults report continuance of sexual activity, feelings of desire, and intimate relationships throughout their lives.⁵^–⁸

During a medical examination, the sexuality of older patients is often not discussed by physicians, and older patients are reluctant to bring up the subject themselves.⁹ Personal beliefs, stereotyped views, and lack of professional medical education are the main reasons for neglecting late-life sexuality during a medical examination. As a result, physicians may fail to diagnose sexual dysfunction and recommend treatment possibilities. Discussing sexuality in later life can offer older patients reassurance about the normal changes in sexuality that may be troubling them. Furthermore, patients should be informed about the possible side effects of medications that can affect sexual behavior negatively.¹⁰

The psychological effect of a sexual problem usually affects both patient and partner. For example, in heart patients, fear of another heart attack or even death during intercourse may interfere with the patient’s and partner’s ability to perform and enjoy having sex.¹¹ Involvement of the partner is an important indicator for therapy to be successful or effective. Psychosexual treatments can vary, ranging from basic sex education through improved partner communication to cognitive behavioral therapy.¹²

Sexuality in Older Men and Women

The World Health Organization (WHO) defines sexuality as follows¹³:

Sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors.

This broad definition underlines the various aspects of how sexuality can be expressed and the variety of difficulties that may occur. However, it also clarifies how asking about the frequency of sexual activity alone is not enough. A study on the perception of sexuality among older adults (mean age, 71 years; 54% women) showed that 42% of respondents agreed that sexuality was still important, and almost 70% reported a continued need for touch and intimacy.⁸ The phases of the sexual response cycle—desire, excitement, and orgasm—remain the same throughout life, although it may take longer to become aroused and more stimulation may be needed.¹⁴ Intimacy also remains important in later life; studies have shown that infrequent sexual touching can be associated with arousal and orgasm difficulties in men and women.¹⁵

Physical problems associated with acute and chronic diseases are more prevalent in older adults. In addition to the physical effects of a medical condition, patients often regard the sexual loss or inability to engage in sexual activity to be the most devastating aspect of their condition.¹⁶ As such, awareness of psychological effects during treatment of a medical condition is essential and requires a holistic approach.

Male Sexuality

With aging, the male orgasm may last a shorter time, with a decreased force of ejaculation and the volume of ejaculate. Increased blood flow through the paired cavernosal arteries is the main mechanism for obtaining an erection.¹⁷ Erectile dysfunction (ED) is characterized as the inability to maintain an erection during intercourse. Studies on prevalence data have reported that 10% of men in their 60s, 15% of men in their 70s, and 30% to 40% of men in their 80s suffer from ED.¹⁸

ED may be an early warning sign of a medical condition, such as diabetes, heart disease, and hypertension.¹⁹ Most ED cases have physical causes, including vascular, neurologic, and endocrine disorders (Table 98-1).¹⁰^,²⁰ Structural abnormalities such as Peyronie disease (incidence, 0.39% to 3.2%) also affect sexual activity.²¹

TABLE 98-1

Effects of Medical Conditions on Sexuality

Medical Condition	Effect on Sexuality	Treatment
Arthritis	Sexual desire is usually unaffected, but disability due to osteoarthritis and rheumatoid arthritis may interfere with performance.	Trying sexual positions that do not aggravate joint pain; planning sexual activity for times of day when pain and stiffness are diminished
Chronic emphysema and bronchitis	Shortness of breath hinders physical activity, including sex.	Rest, supplemental oxygen
Chronic prostatitis	Pain may diminish sexual desire.	Antibiotics, warm sitz baths, prostatic massage, Kegel exercises
Chronic renal disease	Impotence, possibly with anxiety and depression	Dialysis, psychotherapy for underlying emotional problems, kidney transplantation may restore sexual capacity
Diabetes mellitus	Impotence is common.	Very tight control of diabetes may restore potency
Heart and vascular disease
Myocardial infarction	8- to 14-wk recuperation period recommended before resuming sexual intercourse; depression and antidepressant drugs may reduce libido and capacity; fear of bringing on another heart attack if patient resumes sexual activity.	Reassurance from the physician about safety of sexual activity, exercise programs to improve cardiac function
Heart failure	Sexual dysfunction resulting from physical symptoms or medications; a 2- to 3-wk week recovery period is advised before resuming sex in cases of pulmonary edema.	Reassurance from the physician about safety of sexual activity for patients with effectively managed heart failure, exercise programs to improve cardiac function
Coronary bypass surgery	Abstinence for at least 4 wk is recommended before resuming sexual intercourse.	Alternatives such as self-stimulation or masturbation can usually be started earlier in recovery period, exercise programs to improve cardiac function
Pelvic steal syndrome	Example of vascular impotence—male loses erection as soon as he enters his partner and begins pelvic thrusting due to gravity’s redirecting blood supply away from the pelvis.	Changing position may help (man should lie on his back or side)
Hypertension	Incidence of impotence in untreated male hypertensive patients is about 15%; effects on women have not been established.	Choose hypertensive drugs that do not impair sexual response.
Parkinson disease	Lack of sexual desire in men and women; impotence in men	Levodopa can improve sex drive and performance in some men for a limited period.
Peyronie disease	Intercourse is painful for many men with the disease; penetration may be difficult or impossible when penis is angled too sharply.	Psychotherapy to help patient adjust to changes in the penis; symptoms occasionally disappear spontaneously; surgery helps in some cases.
Stress incontinence	Sexual dysfunction has been reported in up to 50% of women with this condition.	Solving the underlying problem may help. Kegel exercises to strengthen muscles supporting bladder. estrogen taken orally or locally to firm up vaginal lining. biofeedback training
Stroke	Sexual desire may not be impaired, but sexual performance is likely to be affected (e.g., male erectile dysfunction because of physical or psychological reasons, anesthetic areas, or physical limitations due to paralysis).	Mechanical adjustments to assist positioning necessary for sexual activities. treatments for impotence

Surgical procedures and the use of medication and substances may also lead to sexual problems (Tables 98-2 and 98-3).¹⁰^,²⁰^,²²

TABLE 98-2

Effects of Surgery on Sexuality

Surgical Procedure	Effect on Sexuality
Hysterectomy	Need to refrain from sexual activity during healing (6-8 wk after surgery), depression, possible reduction in sensation during orgasm
Mastectomy	Emotional reactions such as depression, loss of sexual desire because of emotional reactions of patient and partner
Prostatectomy	Need to refrain from sexual activity during healing (6 wk), possible impotence because of surgery (nerve-sparing techniques help avoid this effect in some cases), possible psychogenic impotence
Orchiectomy	Impotence common
Colostomy and ileostomy	Emotional reactions that can affect desire and potency (participation in ostomy clubs recommended)
Rectal cancer surgery	Impotence common