Sexuality in older age

Sexuality in older age concerns the sexual drive, sexual activity, interests, orientation, intimacy, self-esteem, behaviors, and overall sexuality of people in middle age and old age, and the social perceptions concerning sexuality in older age. Older people engage in a variety of sexual acts from time to time for a variety of reasons. Desire for intimacy does not disappear with age, yet there are many restrictions placed on the elderly preventing sexual expressions and discouraging the fulfillment of sexual needs. Sexuality in older age is often considered a taboo, yet it is considered to be quite a healthy practice; however, this stigma can affect how older individuals experience their sexuality. While the human body has some limits on the maximum age for reproduction, sexual activity can be performed or experienced well into the later years of life.

Both male and female libidos tend to decline with increasing age, and women tend to lose their libido faster than men. However, desire for sexual activity is not lost completely. Neither does it decrease for everyone. Menopause, a female biological process, has been linked to a loss of interest in sexual activity and to a desensitization of the genital area.^[1] In some cases, vaginal penetration can be painful for older women (see, for example, vaginismus).^[2] Vaginal atrophy is another example of a bodily change in women that may make penetration painful, characterized by the thinning of vaginal walls. However, with the advent of hormone replacement therapy (HRT) treatments, the effects of menopause have lessened and women have more opportunities to continue experiencing a pleasurable and active sex life. Similarly, treatments for erectile dysfunction can make it possible for men to enjoy sexual activity again.

It has been suggested that an active sex life can increase longevity among the elderly. Positive sexual health in older age is slowly becoming more of a commonplace idea with the steady increase in the percentage of the older population. This population percentage increase requires placing more attention on the needs of this age group, including their ideas on sexual health, desires, and attitudes. This shift in attitudes and behaviors has combined with medical advances to prolong a sexually active life and change the landscape of aging sexuality.^[3]

Sexual health and expression reflects a physical, mental, and emotional need that affects individual health and intimacy quality for older couples' relationships. Dr. Syme found that, "Having a sexual partnership, with frequent sexual expression, having a good quality sex life, and being interested in sex have been found to be positively associated with health among middle-aged and older adults."^[3]

There are a number of associated health benefits with practicing positive sexual health. Positive sexual health often acts as a de-stressor promoting increased relaxation. Researchers also report health benefits detailing decreased pain sensitivity, improved cardiovascular health, lower levels of depression, increased self-esteem, and better relationship satisfaction.^[3] The former could also imply the consequences of negative sexual health and lack of sexual activity, such as depression, low self-esteem, increased frustration, and loneliness.

There are already numerous health concerns linked primarily with aging, but when sex is added into consideration, this opens up discussion for many other related concerns. Sex and aging come with many challenges for the older population as well as their primary care providers. The task for these care providers is to accommodate to the changing needs of this older sexually active generation.^[3]

Common health conditions hindering older adults are illnesses such as cardiovascular disease, diabetes, degenerative and rheumatoid arthritis, stroke, cancer, kidney disease, and spinal cord injury. These conditions heavily impact individual sex lives.^[3] Separate from these are physical concerns related specifically to sexual health and bodily functions. Researchers gathered that, "the most common concerns for older adult men include erectile dysfunction and premature climax, and older adult women most commonly report lack of desire, problems with vaginal lubrication, sexual pain, and inability to reach orgasm."^[3] Consideration of these aging-related health problems and sexual-related health problems together require primary care providers and professionals to be updated on the latest health findings and to know patients' needs and possible solutions.

A major problem with improving education and seeking solutions for aging sexual health risks is the lack of verbal discussion on these matters from older individuals. "Older adults often avoid seeking help for sexual concerns because of a lack of knowledge about their sexual problems, embarrassment or discomfort talking about sex, and stigma-related beliefs about older adults and sexuality in older age being inappropriate."^[3]

Another major problem with improving education and seeking solutions for aging sexual health risks was found after researchers looked at the readiness and training of 777 physicians and 452 nurse practitioners from the American Medical Association Masterfile.^[4] Researchers noted that amongst their representative sample there were reports of limited training in sexual health as a general topic. From this information, they assumed that "training that is specific to older patient’s sexual health is limited, if available at all."^[4]

The purpose of the study was to test how knowledgeable U.S. primary care providers were on the topics of sexual health and sexuality in older age.^[4] The results of the study showcased that U.S. health care providers on average were less knowledgeable than U.S. graduate nursing students on the topics of sexual health and aging sexuality. In a comparison survey, it is also worth noting that they were reported less knowledgeable than Turkish physicians and U.S. Ob/Gyns. However, the group reported to be even less knowledgeable on aging sexuality than U.S. primary care providers consisted of nursing home staffs and older adult care workers.^[4] Educated health providers are needed to educate the general public and older adults (active and inactive) on sexual health and healthy expression.

Sexually transmitted infections (STDs/STIs) can also be prevalent in later life, despite common misconceptions that STDs only affect younger people and groups. There has been a steady increase in the number of STDs found in elderly individuals in nursing homes and other residential living communities, belying the perception that elderly people do not engage in sexual activity.^[5] Many men in older age do not believe they need to use protection, such as condoms, as they age, and their partners often feel likewise, so it can be difficult to stress the importance of continued use of protection for elderly couples.^[6] One of the main reasons they develop this opinion is because of the decreased risk of pregnancy, but they often fail to acknowledge that protection is necessary to prevent the circulation of STDs.

To better support the aging population, we need to actively involve older adults and disabled individuals in policy making, research, and tailored messaging programs. Research should be used to identify gaps and improve health systems. Policymakers must take into consideration the impact of sexual health (SH) on older adults’ wellbeing. Finally, SH programs and messaging must include and cater to older adults to incorporate the entirety of the sexually active population.

Population aging has direct implications for SH researchers. Older adults are often excluded from population-based SH research studies. A review of STI treatment clinical trials found that 72.7% of risk-reduction clinical trials excluded participants over the age of 50, and 88.8% excluded those over the age of 65.^[7] In order to generate more responsive SHS and engage a population that is often excluded from participatory research, researchers need to include older adults in cohort studies, trials, and other research.

There is a need for empowerment and incorporation of older and disabled adults’ ideas. The Sexual Health in Older Adults Research team used co-creation and related participatory approaches to solicit feedback from older adults in the United Kingdom to improve health services.^[8] This included workshops, open calls, and community discussion involving participants from all backgrounds, including those of “older age” (referenced as >45 years in this study) and those with disabilities. Their collaborative design and process demonstrates that social innovators could use co-creation methods to identify and develop health services that are more responsive to the needs of older adults and people with disabilities. A research agenda that specifically includes these underrepresented groups promotes inclusivity and diversity and generates more evidence for best-practice guidance and programming.

The Sexual Health in Older Adults Research (SHOAR) program ^[9] is one of the few research studies devoted to the sexual health preferences of older adults. Their overall aim was to obtain evidence for improving sexual health services among middle-aged and older adults (45 and older) and generate relevant policy recommendations for local authorities.

Another research team was the Sexual Health in Over ForTyfives (SHIFT). “The project’s objective was to identify and address inequalities related to the sexual health of those aged 45 and above, and to co-design a model to empower those aged 45 and over to improve their overall sexual health, improve access to services, and remove the stigmas and preconceptions associated with sex and older age.”^[10]

In the United Kingdom, the English Longitudinal Study of Ageing (ELSA) includes sections about sexual wellbeing as a pillar of healthy ageing. It found that poorer health was related to lower sexual activity, and could be attributed to poorer aging and lower quality of life.^[11]

These are some of the very limited research studies on sexual health in older adults.

SH policymakers should prioritize the needs of an aging population, ensuring SHS receive funding for accommodating older adults, especially those with disabilities. Anti-discrimination training in health services should cover ageism and ableism. Public health messaging should challenge stereotypes about SH in later life.

Public health communications play a crucial role in enhancing SHS for older adults. Physiological changes associated with aging and a greater prevalence of chronic illness can negatively affect sexual functioning and discourage intimacy among older adults.^[12] Ongoing social stigmas surrounding sexuality, embarrassment and dissatisfaction with clinical interactions, and seeming disinterest from doctors are not new obstacles to older populations concerning SH. However, these obstacles are causing increasingly salient effects as global populations age while continuing to be underrepresented in SH programs, messaging, and education.^[13] HIV and STD sexual health campaigns are common among young people, and older adults are rarely included despite a prevalence of STIs and STDs in sexually active older adults.^[14]

It is a common misconception that people lose interest in sex or become sexually inactive in older age.^[15] One survey in England of people aged 60-69 recorded 86% of men and 60% of women as sexually active.^[15]

Sex between elderly people is often treated as a taboo by society. Cultural norms dictated social opinions which painted older adults as being asexual creatures. This opinion was supported and replicated in the media by showing sex only being popular among youth.^[16] This attitude has gradually changed because a greater number of people are reaching 55 and above, and are remaining sexually active far into their senior years.

Back in 1930, less than 6 percent of the U.S. population was over 65 years old. By 1950, the number was 8 percent. By 2015, that number has risen to almost 15 percent. Population experts at the U.S. Bureau of the Census expect the percentage to continue to rise dramatically during the next 20 years, eventually reaching 21 percent by 2050, which is more than one in five. The number of seniors in the United States and throughout the world continues to increase rapidly.^[17][18]

While sexual activity itself is a sensitive topic due to its private nature, sexual activity between seniors is often treated with extra care. This attitude is especially common among younger people and it has been suggested that this may be caused by younger people's belief that the lust and ability to have sex diminishes once a perceived primary reason for sex is no longer present.^[19]

Even though the topic may be taboo or denied, sexuality in older age has gained visibility in the media.^[20][21] Some sources promote "active" and "healthy" sexuality among the elderly,^[22] or address issues such as sexuality in retirement homes and assisted living facilities. These representations create in turn social injunctions that position sexual activity as a marker of fulfillment,^[23] a discourse already affecting younger people and amplified by various products, pills, and available medical treatments.

Research conducted in the social sciences changes the miserable depiction often made of elders' sexuality.^[23] Quantitative and qualitative studies show that sexual satisfaction can improve with age, and they present data such as the following. Half of women are sexually active into old age.^[24] Widows either stop any kind of sexual activity, find a new male partner, or choose not to reproduce the same kind of relationship where they take care of a man, instead entering into a nonresidential relationship with a man or in a relationship with another woman, for example.^[25] Women and gay men sustain the most pressure to live up to beauty ideals associated with youth.^[26] LGBT people suffer from invisibility in retirement homes and assisted-living facilities.^[27]

In general, many older adults that define themselves as a part of the LGBTQ+ community do not feel as comfortable talking to their physicians about sexual health. Many fear homophobic responses, or believe that their GP is not willing to talk to them about sexual health.^[28]

To many, The Golden Girls was groundbreaking in its depiction of healthy active sexual lifestyles and frank sexual discussion among seniors.

In the early 1990s, The British sitcom Waiting for God (TV series) featured two protagonists who were resident in a retirement home for older people, engaging in casual sex together.

The concept of active sexual relationships between older people has in recent years become a more mainstream topic. The film Something's Gotta Give, starring Jack Nicholson and Diane Keaton, explores the relationship that develops between two people in later life.

The HBO series Tell Me You Love Me has caused controversy by showing several explicit sex scenes involving two senior citizen actors on the show, Jane Alexander and David Selby.

On a related topic, intergenerational relationships, also quite taboo, were the focus of the film Gerontophilia (between a very old and a very young man), and in the last years many TV shows represented "cougars" (middle age women with younger men), for example The Cougar and Cougar Town.

The Netflix original, Grace and Frankie, features Jane Fonda and Lily Tomlin as two elderly women recently divorced from their husbands seeking guidance through life with the help of each other. Not only does the show highlight their sexual quests and struggles with their new partners, it also mentions their new partnered business-seeking venture to encourage personal, private intimacy for women their age. The "Ménage à Moi", as they have it named, is a vibrator targeting elderly women to use for sexual satisfaction, and the show features the struggles surrounding marketing such a product.