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Addressing Sexuality and Sexual Dysfunction
by Marc E. Agronin, M.D.
Geriatric Times January/February 2001 Vol. II Issue 1
Views of late-life sexuality are often based on ageist stereotypes that it either does not exist or is beset by dissatisfaction and dysfunction. Such stereotypes and misinformation lead many clinicians to take a pessimistic attitude toward late-life sexuality or make jokes about it. Today, both clinicians and patients have become more comfortable and open about discussing sexual issues, and attitudes toward late-life sexuality will continue to change as the aging baby-boom generation-which brought society both the sexual and the feminist revolutions-becomes geriatric.Satisfaction Rates
As Michael L. Freedman, M.D., professor of geriatric medicine and director of the Diane and Arthur Belfer Geriatric Center at New York University School of Medicine, has expressed (1999), "With reasonable personal health and an available partner, most elderly persons continue sexual relations into their eighth and ninth decade." His statement is supported by a number of studies demonstrating that a large percentage of individuals over the age of 65 not only continue sexual activity, but are generally satisfied with sex and with their partners.
These studies reveal a modest decline in the rate of sexual activity with increasing age compared to rates for younger individuals, more so for widowed women. For example, a mail survey of nearly 1,400 men and women 45 years and older conducted by AARP and Modern Maturity (MM) magazine (1999) found that three-quarters of both men and women over the age of 45 who had steady partners remained sexually active. The study found that 84% of men and 78% of women ages 45 to 59 had sexual partners, compared to 58% of men and 21% of women 75 years and older. Looking at frequency of sexual intercourse, just over 60% of men and women ages 45 to 59 with steady partners reported having sex at least once a week, compared to approximately 25% of men and women 75 years and older. In the AARP/MM study, two-thirds of respondents with sexual partners were extremely or somewhat satisfied with their sex lives. Moreover, the consensus across studies is that the major predictors of sexual interest and activity in late life include the previous level of sexual activity, the health and sexual interest of a partner, and an individual's overall physical health.
Sexual Function and Aging
There are a number of age-associated changes in sexual function that both sexes face (Spector et al., 1996). For women, the decline and eventual cessation of estrogen production during menopause leads to atrophy of urogenital tissues and an overall decrease in genital vasocongestion and lubrication during sexual arousal. As a result, sexual desire may decrease, orgasm may be less intense, and genital stimulation during sex may be less effective and less comfortable without the use of external lubrication. Hormone replacement therapy will reverse these changes in many women. Despite mild declines in testosterone production in men, there is no equivalent male menopause or "andropause" that alters sexual function or fertility to the same degree as occurs in women (Metz and Miner, 1995). Sexual arousal in men may take longer and require more genital stimulation, and erections tend to be less durable and less reliable. Ejaculatory volume decreases and the refractory period can increase significantly.
Sexual Dysfunction
Sexual dysfunction is by no means an inevitable occurrence in geriatric patients, although its prevalence certainly increases with age. Erectile dysfunction (ED) is the most common form of sexual dysfunction in older men, affecting over 50% of men ages 40 to 70 and nearly 70% of men age 70 (Althof and Seftel, 1995; Feldman et al., 1994). Hypoactive sexual desire and premature ejaculation are also seen in geriatric patients, but these phenomena occur less often. Although there are limited data on the prevalence of sexual dysfunction in older women, hypoactive sexual desire, inhibited orgasm and dyspareunia (pain during sex) are the most common disorders (Renshaw, 1996).
Medical and psychiatric disorders are the most common causes of sexual dysfunction in geriatric patients. For example, several common causes of ED include peripheral vascular disease, diabetes mellitus and nerve damage due to prostate surgery. In women, inhibited orgasm and dyspareunia can result from radiation therapy or surgery used to treat various types of gynecologic cancers. In both sexes, fatigue, pain and physical disability due to medical illness can make individuals feel less sexy and less confident in their sexual ability. This can lead to hypoactive desire.
Psychiatric illnesses, especially major depression and dementia, are frequently associated with sexual dysfunction in late life. It is common knowledge that low libido is a cardinal symptom of depression. Men with Alzheimer's disease suffer from high rates of ED, in part due to progressive impairment in their ability to maintain a cognitive focus on sexual stimulation during sex. Psychosocial stresses such as the loss of a partner due to disability or death, fears of self-injury or death due to medical conditions (e.g., history of myocardial infarction, shortness of breath), or sensitivity to loss of personal appearance or control of hygiene (e.g., due to incontinence or the presence of a colostomy) can sometimes spell the end of an individual's desire for sexual activity. The availability of partners is an acute issue for women, who outnumber men by over two to one by the age of 85.
Finally, the impact of medication cannot be underestimated and can affect all stages of sexual function (Crenshaw and Goldberg, 1996; Goodwin and Agronin, 1997). Psychotropic medications, in particular, are common culprits across the lifespan (Gitlin, 1994).
Assessment and Treatment
The preservation and enhancement of sexual activity in geriatric patients requires an understanding and sensitivity to the fact that many of these individuals want and intend to continue sexual activity, despite normal and pathologic changes in physical and sexual function. Clinicians can help patients gain an expanded view of sexuality as a form of physical and psychological intimacy and not solely as sexual intercourse. It is sometimes important for couples with physical disabilities to shift focus from intercourse to foreplay and to adapt sexual positions and practices that account for limitations such as fatigue, loss of muscle strength or pain. Organizations such as the American Cancer Society (Schover, 1988), the United Ostomy Organization, and the National Jewish Center for Immunology and Respiratory Medicine have published excellent brochures on maintaining sexual function in the face of specific medical illnesses. When medications may be impairing sexual function, physicians can consider alternative agents or even antidotes to reverse side effects (Segraves, 1998). Treatment of a medical illness or disability that interferes with sexual activity should be maximized, using such modalities as physical therapy when muscle weakness is a problem, prn analgesics for pain and prn inhalers when shortness of breath is a problem. Appropriate treatment of mental illness can often lead to significant improvement in sexual function, assuming that the medications themselves have not caused problems.
When one partner suffers from dementia, sexuality can often continue to play an important role in the relationship by providing a nonverbal means of communication and intimacy. Ethical issues arise, however, when one partner is not fully competent to consent to sex or when the nonaffected partner seeks to fulfill sexual needs outside of the relationship. Issues of competency can be addressed through psychiatric evaluation of the demented partner and then discussed with the nonaffected partner.
Treatment of ED in geriatric men involves all of the same approaches as with younger men, and it has certainly been revolutionized with the advent of oral erectogenic agents such as sildenafil (Viagra). Sildenafil acts by inhibiting the penis-specific enzyme phosphodiesterase type 5, leading to prolonged smooth muscle relaxation and induction of erection when accompanied by direct physical stimulation. Phentolamine (Regitine) and apomorphine (Uprima) are two other oral agents that may soon be available on the U.S. market. Erectile dysfunction can also be treated by an intracavernosal injection or a urethral suppository of alprostadil (Caverject, Edex, Muse), a synthetic form of prostaglandin E1. Several other injectable agents, including papaverine and phentol-amine, have also been used. Although injectable agents work well within 10 to 30 minutes and are generally well-tolerated, some men are put off by the use of needles, while others suffer from mild discomfort and scarring with repeated use. Vacuum constriction devices are a less invasive method of inducing erection. Such devices have a good success rate but require some dexterity and tinkering to perfect, and they can cause mild pain and numbness in the penis. Although they have been falling out of favor, surgical prosthetic devices have also been used successfully to treat ED across the lifespan.
In some couples, sexual dysfunction has clear psychological roots, often in the context of a dysfunctional relationship. Therapy is always best when both partners are involved, since both are an integral part of the problem and solution. The first step in assessment is to conduct a thorough sex history with both partners in order to identify factors from past and present sexual attitudes and experiences that may be critical to the problem. Sex therapy then begins with exercises called sensate focus, in which the couple learns relaxation techniques and then applies these to non-pressured sensual touching. Once a couple is able to feel relaxed and physically intimate together without sexual stimulation, they gradually progress to genital stimulation and then intercourse. The resistance to these seemingly innocuous exercises often serves to identify key problems in the relationship that are either causing the sexual dysfunction or impeding its treatment. Cognitive-behavioral therapeutic techniques are also employed to reduce performance anxiety, as well as to refocus distorted cognitive attitudes toward sexual activity into more practical ones. Many couples find that both sensate focus and counseling lead to improvement, if not resolution, of sexual dysfunction.
Dr. Agronin is a board-certified geriatric psychiatrist who currently serves as the director of Mental Health Services at the Miami Jewish Home & Hospital for the Aged and voluntary assistant professor of psychiatry at the University of Miami School of Medicine. He is the co-author of A Woman's Guide to Overcoming Sexual Fear & Pain (1997) published by New Harbinger Publications.
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