Sexuality in Older Adults Sexuality and Reproduction Mary

Sexuality in Older Adults Sexuality and Reproduction Mary Mc. Donald, MD

Definition of Sexuality The psychological and behavioral aspects of sexual expression in complex organisms.

Old People Have Sex

There has been relatively little research on sexuality in later life, particularly among persons over 60 years of age. Why is that?

What the Stats say n n n Recent study by AARP reveals that many people remain sexually active into their 70 s. The Janus report found that in patients > 65, 69% of men and 74% of women report some form of sexual activity at least weekly Breshneider and Mc. Coy study of patients aged 80 -102, 72% of men and 30% of women engage in sexual intercourse

Societal/Cultural Views Negative images and stereotypes abundant in US culture n Sexuality in older persons seen as unseemly, even unnatural n Sex is for beautiful, young people n Leaves many older adults feeling asexual n

“we’re supposed to be asexual, and those who refuse to be so are branded dirty old men” De. Lamater and Sill

Another Misconception Vaginal intercourse is the only “real sex” Hands and mouths are reliable; penises and vaginas are not De. Lamater and Sill

Decline in Sexual Activity Medications n Illness n Urinary incontinence n Partner availability n Relationship problems n n Above reasons likely contribute to decline more than aging itself

Medications Interfering with Sexual Functioning n n n n Anti-hypertensive's Diuretics Anti-arrhythmics Opiates Antihistamines Anti-cholinergics Stimulants antidepressants n n n Lipid-lowering agents Anti-estrogens Anti-androgens Exogenous hormones Also: alcohol and tobacco

Illnesses Interfering with Sexual Functioning Vascular Disease n Heart Disease n Diabetes n Arthritis n Depression n

Cardiovascular Disease and Sexual Functioning Inadequate vascular supply to pelvis problematic for arousal n Poor exercise tolerance, dyspnea on exertion, exertional angina n Many cardiovascular meds can interfere with normal sexual response n

Diabetes and Sexual Functioning Neuropathic changes to pelvic/genital nerves can interfere with normal functioning n Highly susceptible to polypharmacy n

Arthritis and Sexual Functioning Joint pain and lack of flexibility can interfere with sexual positioning n Narcotic pain medication can interfered with normal sexual response n

Depression and Sexual Functioning Generalized anhedonia interferes with sexual desire n May interfere with relationships, thus a partner for sexual activities n SSRI, TCA antidepressants interfere with normal sexual functioning n

Urinary Incontinence and Sexual Functioning n Women report urinary incontinence interferes with sexual fulfillment n n Low libido Fear of urine leakage during sex Depression Embarrassment Tannenbaum, et al

Partner Availability In the U. S, there are 26. 6 million men and 33 million women over the age of 55 Only 74% of the men and 50% of the women are married and living with a spouse Smith

Approach to Sexual Interview EVALUATE your own attitudes, feelings, values regarding sexuality n DEMONSTRATE sensitivity to patients beliefs and values n AVOID Medical Jargon n REMAIN NONJUDGMENTAL n IDENTIFY when the problem began, how it developed (gradually or suddenly), and what factors make it better or worse. n

Approach to Sexual Interview n n n ASK the patient to describe his/her behavior, emotional reactions, and thoughts from start to finish during a recent sexual experience both with and without a partner OBTAIN a complete medical history to identify biomedical and psychiatric illnesses, trauma, surgery or medications. ASSESS psychosexual and relationship history.

Approach to Sexual Interview EXPLORE options for non-coital and/or non -genital sexual expression n DISCUSS sexually-transmitted infections, including HIV, and review safe sex guidelines n Nusbaum, et al

Communication-Older Woman More likely than men to seek medical care for sexual problems n Easier if physician initiates the discussion n A sense of caring and a continuous medical relationship facilitates n Little difference if physician is male or female n

Communication- Older Men Overall less likely to make appointment to discuss any particular health issue n Health-seeking behaviors often initiated by women in their lives n

Basic Sexual Counseling for Older Adults n n Avoid sexual interaction at times of day when pain, fatigue, or stress are highest Engage in ample non-genital and genital touch Include non-demand touch (massage, handholding) that is not linked to sexual activity Discuss varying sexual positioning to reduce pain and maximize sexual stimulation for each member of the partnership

Basic Sexual Counseling for Older Adults n n Take turns at giving both sexual pleasure as well as non-demand touching Limit alcohol and tobacco use Expand sexual repertoire to include erotic literature, sexual lubricants, fantasy, selfstimulation Talk more with one’s partner about what is pleasurable Nusbaum, et al

Sexual Arousal Cycle Desire n Arousal n Plateau n Orgasm n Resolution n

Desire Phase Androgen levels decrease in men and women with age n Study by De. Lamater et al reveals that not until age 75 or older that the majority of women and almost a majority of men report a low level of sexual desire n Exogenous hormones, antidepressants and some diabetes meds may interfere n

Arousal and Plateau Phase n n n Requires intact parasympathetics and vascular system Diminished estrogen in postmenopausal women can lead to decreased lubrication Study by Feldman, et al reveals up to 52% of men (age 40 -70) had some degree of erectile dysfunction.

Orgasm Older women remain capable of multiple orgasms but sensation may be lessened due to decreased muscle tone n Force and volume of male ejaculation may diminish and may not occur with every sexual encounter n Rapid ejaculation less problematic but prolonged ejaculation more common n

Resolution Return to pre-excitement phase occurs more rapidly in older men and women n Refractory period significantly increases in older men n

The Older Gay and Lesbian Patient May be resistant to volunteer information on their sexuality n Aged prior to sexual revolution n Communication aided by nonjudgmental, accepting stance n Gender neutral language, “partner”, may be helpful n

Sexuality in Nursing Homes Sexual expression is often not fostered, but restrained n Personal values of NH staff may supersede rights of patients n Sexual expression often labeled, “sexually inappropriate behavior” n By law, facilities must accommodate privacy needs of consenting adults n

Ethical/Legal/Financial Concerns in NH Ability of both partners to give consent for sexual activity n Family disapproval n Staff/resident social comfort n Lack of adequate space for privacy n

STDs in Older Adults Grossly overlooked by medical professionals n Low levels of condom use in older adults as often associated with pregnancy prevention only n Older men may have multiple partners available. By age 85, women outnumber men by 3: 1 n

STD in Older Adults n n Patients over the age of 50 account for 10% of reported HIV cases In 1997, patients over the age of 55 accounted for n n n 4% of primary and secondary syphilis cases 1% of cases of gonorrhea Prevalence of HSV-2 increases with increasing age Calvet and Bolan

References n n n Bretschneider JG, Mc. Coy NL. Sexual interest and behavior in healthy 80 to 102 year olds. Arch Sex Behav 1988; 17: 109 -129. Calvet, Helene M and Bolan, Gail. STDs in Older Adults: the Need for Increased Awareness. Clinical Geriatrics. 2000 De. Lamater, John D; Sill, Morgan. Sexual Desire in Later Life. The Journal of Sex Research. May 2005 Feldman, HA, et al. Impotence and Its Medical and Psychosocial Correlates: Results of the Massachusetts Male Aging Study. J Urol 2994 Janus SS, Janus CL. The Janus Report on Sexual Behavior. New York: John Wiley & Sons, 1993; 25. Nusbaum, Margaret R. H, DO, MPH, et al. Sexual Health in Aging Men and Women. The Psychiatric Consultant

References n n Smith, D. (2003). The older population in the United States; March 2002. Washington, DC: United States Census Bureau, Current Population Reports Tannenbaum, MD, MSc, et al. The Relationship Between Sexual Activity and Urinary Incontinence in Older Women. JAGS, 2006