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CHAPTER 5 Sexuality and ageing
Serena P. Wong1 and Kahli E. Zietlow2
1 Duke University School of Medicine, Durham, NC
2 University of Michigan Department of Medicine, Ann Arbor, MI
Introduction
Sexuality is an important component of quality of life throughout the lifespan, and its expression is dependent on biological, psychological, and social factors. Studies have demonstrated that sexual activity is associated with improved quality of life and life satisfaction.1‐3 Sexuality is much more than the physical act of sex and encompasses intimate feelings, sensuality, and the way people view themselves in terms of gender expression. Relationships are influenced by sexuality, and cultural codes set the boundaries of what are considered to be acceptable or unacceptable behaviours. Myths and prejudice abound in terms of societal and professional expectations about the sexual behaviours of older people, and their needs in this area can easily be overlooked and misunderstood. This chapter describes the sexual health of older adults; issues pertaining to ageing and chronic disease, including dementia; and topics specific to different groups of people.
Sexual health in older adults
Sexual function is described as ‘one’s ability to engage in sexual expression and sexual relationships that are rewarding, and the state of one’s physical, mental, and social well‐being in relation to their sexuality’.4 Good physical and mental health, positive attitudes toward sex in later life, and access to a healthy partner are key factors leading to long‐term sexual activity.4 In the United States, a survey of people aged 57–85 years found that 73% of people 57–64 years of age and 26% of people 75–85 years of age were sexually active.5 The survey defined sexual activity as ‘any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs’. This survey also showed that sexual problems existed in half of the population, but only 38% of men and 22% of women had discussed these issues with a physician. Although open discussion of sexuality has become much more common in recent decades, many older people may consider sexuality a taboo subject. Cultural norms and values are changing, and it is likely that future generations will be more assertive in terms of seeking healthcare advice and interventions to address their sexual health. However, it is important to recognize that current prejudices and myths about celibacy dominate Western views of sexual activity in later life, and this may inhibit older people from seeking help with sexual performance, sexual health, and relationships.
Many variables affect older adults’ attitudes toward sex and sexuality, including personal experience, pressure from family members, social and cultural norms, religion, and spirituality.6 Among older adults who are no longer interested in sex, some reasons include feeling that they are too old or too ugly, and health issues that affect their interest in sex.7 The presence of a sexual partner can be one of the stronger influences on an older adult’s attitudes toward sex with increasing age. Those who have a current partner place more importance on continuing sexual activity than those without a partner.6 Among older adults who are sexually active, there may be a shift from sexual intercourse to other activities such as kissing, cuddling, intimate touching, oral sex, and masturbation,2,7 possibly to accommodate physical and functional limitations.
Providers for older adults should routinely screen for sexual health‐related concerns using neutral and non‐judgmental language. Some patients may not be comfortable discussing such concerns with their physician. We recommend the following approach: Ask patients’ permission to inquire about their sexual health with an opening question such as, ‘May I ask you some personal questions about sexual activities?’ If necessary, normalize the question by assuring them this is a matter you discuss with all of your patients and explaining that sexual health is related to overall health status. If the patient gives you permission to proceed, ask, ‘Are you sexually active?’ Be prepared to define or clarify what this means. If the patient answers in the affirmative, ask if the patient has sex with men, women, or both, and inquire about the number of partners in the past year. Be sure to ask about safe‐sex practices and whether the patient is using reliable protection from sexually transmitted infections (STIs). Finally, ask whether the patient has any concerns about their or their partner’s sexual activity.
Sexuality and the older woman
The major sexual problems reported by older women include lack of interest in sex, difficulty with lubrication, inability to climax, finding sex not pleasurable, and pain (most frequently at the vagina during entry).4,5,8 While some women have reported sexual problems, other older women view sex in older age as more fulfilling, partially due to having better communication skills and being able to focus on their own pleasure instead of feeling the pressure of ‘keeping a partner present or interested’.7,8 Some women view intercourse without the possibility of conception as liberating, while others express disinterest in sexual activity in older age.
First‐line therapies for women with vaginal dryness and dyspareunia include vaginal moisturizers and lubricants, which can be effective when used on a regular basis. Oral, transdermal, or vaginal oestrogen therapy (available in the form of creams, tablets, or rings) can alleviate sexual dysfunction due to vulvovaginal atrophy.9 Prasterone, or vaginal dehydroepiandrosterone (DHEA), is a daily vaginal suppository approved to treat dyspareunia. Its efficacy has not been directly compared with vaginal oestrogen, and its use leads to a slight increase in circulating DHEA, testosterone, and estrone levels, leading to some concern about its use in women with oestrogen‐sensitive malignancies. Ospemifene is an oral selective oestrogen receptor modulator (SERM) with oestrogen‐agonist effects in the vagina but without effects in the breast or endometrium. It is also approved to treat dyspareunia and vaginal dryness due to vulvovaginal atrophy and is an oral alternative to nonpharmacological or intravaginal treatments.10 Table 5.1 describes therapeutic options for