Shooting Pool with a Rope: The Greying of Sex
This article appeared in the March/April 2007 issue of the NYS Psychologist, the official journal of the New York State Psychological Association. It is reprinted with permission of the executive editor of the publication.
Introduction
George Burns once quipped that sex after 70 was like “shooting pool with a rope.” This self-deprecating joke is a fairly mild reflection of a cultural attitude regarding sex in the later years of life. The desires and sexuality of mature adults have historically been subjects of controversy and mirth (Walz, 2002). “Dirty old men” were the stuff of derision or humor in opera, literature and film. Rossini’s villainous Dr. Bartolo, in the opera “The Barber of Seville,” typifies the commedia dell’arte stereotype of the pathetic old man lusting after a beautiful young woman who outwits and humiliates him in the end. Sexually active older women were often treated even more unkindly. Mrs. Robinson, in the film The Graduate was portrayed by Anne Bancroft as a predatory and ruthless virago. In The Producers, sexually hungry elderly women are presented as either clownish or monstrous.
Until very recently, sympathetic portraits of older adults desiring or engaging in sex were rare. Now, as the baby boomer generation heads toward maturity, it is understood that sexuality is no longer the exclusive province of the young. Recent New York Times articles –“The Graying of Naughty” (Waxman, 2007) and “The Greatest Generation Learns About Great Safe Sex” (Kilgannon, 2007) — feature mature porn stars and sex education classes for seniors, respectively.
As Americans live longer, into their 70s, 80s, 90s and even 100s, they have begun to expect to sustain the same quality of life they enjoyed in their middle years. Despite the biological alterations in physique, hormonal changes and the depredations of aging, many seniors expect to exercise, drive and otherwise maintain mobility, enjoy a full social life, wear stylish fashions and, increasingly, to participate in sexual activities. This article is intended to inform clinicians about the sexual needs and concerns of their elderly clients and how to best address and facilitate them. We will first discuss the biological and medical aspects of the subject, including the risks of sexually transmitted diseases. We will look briefly at sexual issues in nursing homes. The last section gives suggestions for exploring sexual issues with seniors in psychotherapy with clinical illustrations.
Sex in the Second Half of Life
While the ability to procreate drops off dramatically in the second half of life, the ability to perform sexually continues well into old age (Richardson & Lazur, 1995). This is especially true if individuals comprehend and accept the physical changes occurring in their aging bodies and the adaptations necessary to allow sexual enjoyment to take place (Bloom, 2000; Reddy, 2000). In this section, I look at the data on frequency and variety of sexual behavior in the second half of life, review the physical and hormonal changes that affect sexuality and list the effects of disease and dysfunction on sexual capacity. Where relevant, I will examine the role of the psychologist in identifying problems and helping clients to resolve them.
Frequency and Variety of Sexual Activity
Since Kinsey’s groundbreaking studies in the middle of the last century, it has been documented that many older individuals engage in and enjoy sex (Kinsey, et al., 1948, 1953; Masters & Johnson, 1966). Kinsey (1948) found that sexually active older men were having sex regularly (an average of weekly), while sexually active older women experienced it at a rate that compared to their frequency of sexual activity in their late teens (Kinsey, 1953). Estimates of the number of seniors actually having sex vary according to age, marital status (or availability of a partner), physical mobility and views about sexuality in the second half of life (Diokno, et al., 1990; Hillman, 2000).
Overall, there appears to be a gradual decrease in sexual activity with aging, even when controlling for health-related variables (Matthias, et al., 1997). For older women, marital status is a better predictor of sexual activity than age because they are less likely to engage in sex outside of marriage (Matthias, et al.; 1997) while older men appear to have other options (non-marital partners, prostitutes, younger women). Interestingly, surveys of sexual satisfaction show that 65% of seniors were satisfied with their level of sexual activity, regardless of the frequency of the activity. Seniors who were not engaging in any sexual activity were just as likely to report satisfaction as those who were.
Changes with Age
In women, the most significant changes in sexual functioning are the result of menopause. These changes include loss of vaginal elasticity and lubrication, which can lead to discomfort and even bruising and bleeding during intercourse (Gelfand, 2000; Reddy, 2000). The sexual response cycle in women also slows down so that arousal and orgasm may take longer to achieve (Hillman, 2000). The belief that menopause reduces a woman’s sexual interest appears to be a myth (Nordhus, et al., 2005). The physical changes, however, require sensitivity and understanding for both partners to surmount, including use of lubricants, longer foreplay and additional time to climax (Hillman, 2000). Older women can remain capable of intense, satisfying and multiple orgasms (Hillman, 2000). Indeed, for many women, menopause and the cessation of fertility can be liberating, as sex can now be enjoyed for its own sake without the complications of fertility (Hillman, 2000). Masters and Johnson (1966) concluded that older women were likely to be more limited by their attitudes toward sex, their values and the accessibility of partners, than by their biology. Current research substantiates this finding (Nordhus, 2005).
In men, aging can result in a reduction in sexual desire, less firm erections, delay in achieving erection, decrease in penile sensitivity and delay of orgasm (Reddy, 2000). Older men who are ignorant of these normal changes may panic at the fear of impotence and give up on sexual activity altogether (Nordhus et al., 2005). Impotence is probably the most feared male symptom of sexual dysfunction and many men are reluctant to admit to it or internalize ageist beliefs that it is inevitable and incurable. Yet, research findings with a sample of elderly Dutch men show that as many as 28% of sexually active older men may be impotent, suggesting that “normal erections are not an absolute prerequisite for a sexually active life,” (Blanker, et al., 2001, p. 763). Impotence is usually treatable with both medical solutions (medication, implants) and many psychological techniques that improve sexual potency (e.g., sensate focus). Sometimes the solution is as simple as taking more time during sexual activity and increasing physical stimulation. One advantage that older men have over younger men is the ability to maintain erections for much longer periods (Reddy, 2000). Psychologists can educate older clients about these physiological changes and what can be done to counteract or capitalize upon them.
In both men and women, bodily changes caused by aging make some individuals feel that they are no longer attractive or sexy. This is especially true for people whose physical attractiveness formed a central core of their personality, particularly individuals with narcissistic and hysterical personality traits. Changes in strength and vitality, changes in skin and body structure, and the difficulty in finding clothes that fit properly can be traumatic for those who prided themselves on their sexual charisma. For these people, the challenges of aging combined with internalized ageism present serious obstacles for healthy aging and the maintenance of an active sexual life (Hillman, 2000). Such symptoms as depression, anxiety, somatization or substance abuse may bring these clients into therapy ultimately to deal with real losses in self image and self-esteem.
Diseases. Dementia and Incontinence
There are many medical conditions that interfere with or inhibit sexual functioning. Among them are diabetes (Whitehead & Klyde, 1990), arthritis, high blood pressure, heart disease, kidney disease, stroke and physical disability. Parkinson’s disease doesn’t directly interfere with sexual functioning, but the effects of the disease may make one feel less sexy or sexually competent. In addition to the effects of these conditions, the medications prescribed for them can interfere with sexual functioning and/or reduce libido. This is also true for many anti-depressants, commonly prescribed for older medical patients. Parkinson’s medications, on the other hand, are known to cause hypersexuality, that is, an increase in sexual interest and potency.
Psychologists have a role in helping clients with chronic illnesses keep their sexual lives intact. Even when physicians cannot successfully treat impotence and other kinds of sexual dysfunction, clients can be educated about “alternative methods of sexual fulfillment and gratification” and offered supportive counseling and psychotherapy to deal with perceived losses (Whitehead & Klyde, 1990).
Dementia provides a particular challenge for aging couples. The caretaking partner may no longer wish to engage in sexual activity with their increasingly regressed spouse. They may feel disgust, distance or exhaustion. Even in the early stages of the disease, the intact partner may withdraw sexually. On the other hand, in some couples, the affected partner may be soothed by sexual activity, more adventurous because of disinhibition, or stimulated by the intimate caretaking activities increasingly required. Whether or not to be sexual and how with an increasingly demented spouse is a challenge to be negotiated by each couple, individually. Once again, psychologists can be helpful to individuals and couples who are experiencing the effects of disease on their sexual lives by providing psycho-education regarding these effects and ways to counter them, and by helping clients to better understand their feelings and reactions toward ageing and toward their partner.
The final condition to be discussed is incontinence. It is estimated that up to one third of community living older adults and more than one half of nursing home clients experience incontinence, at least temporarily, so this is not an insignificant problem. While incontinence does not affect sexual function, it does affect one’s feelings of attractiveness, vitality and agency. As a medical problem, incontinence is frequently treatable, particularly by behavioral means. Embarrassed and ashamed, many clients might never reveal this problem to a partner or their medical doctor. Incontinence can often be treated with behavioral means, such as Kagel exercises, as well as with medications. All therapists dealing with older clients should be at least familiar with this information and prepared to offer help in finding solutions.
Sexually Transmitted Diseases in Seniors
A British study (Rogstad & Bignell, 1991) cautioned that “Age is no bar to sexually acquired infection.” In a sample of 242 clients over 60, 69% of the men and 53% of the women were sexually active. Nearly 25% were found to have or have had sexually transmitted diseases.
More recent reports from the U.S. Centers for Disease Control and Prevention suggest an increasing incidence of HIV and AIDS among the elderly, a problem which they predict will only grow worse (Anderson, 2005). The fastest growing demographic group showing new HIV infections is older Americans. Risk factors for this age group include use of prostitutes (of both sexes), illicit drug use and failure to use condoms. (Older males are the least likely to use condoms.) Despite these numbers, elderly Americans are also the least likely to be targeted for HIV prevention messages and are more likely to be ignorant of risk and prevention. Health care providers are usually unlikely to bring up the subject of sex with older clients. They rarely ask seniors about sexual activity, let alone their use of prostitutes or illicit drugs, multiple partners, sexual assault or date rape.
Psychologists have an opportunity to be out in front on this issue. Clients usually feel more comfortable discussing sex with their therapists than with their physicians. Psychologists are in a better position to ask their clients intimate questions about sexual desires and activities, to identify their concerns, and to educate them. They can urge clients to speak with their physicians when necessary, and, with the client’s permission, serve as an intermediary with physicians when clients are too uncomfortable to initiate the discussion, themselves.
Sex and the Nursing Home Client
Research suggests that residential and nursing home clients can and do enjoy sexual activities. Male residents tend to be more likely to engage in sexual behavior than female residents and the frequency of sexual interactions is positively correlated with how important sex was for the individual and how often it was engaged in before institutionalization (Bretschneider & McCoy, 1988).
The idea that nursing home clients may legitimately engage in sexual activity is a relative recent and revolutionary concept. Sexual expression is interpreted as a “right” in the nursing home bill of rights, resulting from the 1987 Nursing Home Reform Act. The nursing home bill of rights mandates providing private space for conjugal visits and for letting spouses who are both residents share a room if they wish.
Despite this policy change, sexuality is still considered a behavior problem in many, if not most, nursing homes (Reingold & Burros, 2004). While many nursing home clients remain capable of and interested in sexual activity, impediments to carrying out their desires include “lack of privacy, chronic illness, lack of a willing partner . . . attitudes of physicians and staff, feelings of unattractiveness and an insufficient understanding of sexuality.” (Richardson & Lazur, 1995). Overcoming these obstacles requires that staff be taught about the sexual needs and capabilities of older residents, that residents be evaluated for competency, and that opportunities and private places for sexual expression be created within the facility (Richardson & Lazur, 1995). Nursing home staff and administrators need to develop “an environment that is supportive of residents’ sexuality rights, that permits sexuality expression and promotes a culture where all people concerned are comfortable with sexuality issues” (Roach, 2004). The failure to address the problem of sexuality in old age “essentially robs them [seniors] of a fundamental element of self-worth” (Hajjar & Kamel, 2003).
While research shows that health care providers tend to express permissive views of elderly sexuality (Damrosch, 1984; Glass & Webb, 1995, cited in Hillman, 2000) this attitude does not always translate into practice when dealing with the real life problems of real life clients (Hillman, 2000). Psychologists, in particular may have a unique opportunity to help other nursing home staff deal with inappropriate behavior without being punitive or restricting the residents’ freedoms.
Listening and Normalizing
Two important functions of therapists involve allowing the client the opportunity to reveal and discuss intimate concerns in a safe and nonjudgmental environment. Sexual concerns may be difficult to bring up at any age, but older clients may find this topic especially forbidding given cohort-related feelings of impropriety or embarrassment. This may be doubly the case given some older clients’ internalized ageism. It is the job of the psychologist to listen for derivatives of a client’s veiled sexual interest within the material and help to make it safe for the client to reveal. This may be as simple as asking: “Is there anything that you would like to discuss that we haven’t gotten to yet?” or “I’m wondering if there is something you would like to talk about but feel uncomfortable bring up?” Even if the client isn’t yet ready to bring up the subject, it provides an invitation which may be accepted at a later time.
Some clients require more direct questioning: “I’ve noticed that several times you’ve started to talk about sex (romance, desire, or passion) and then changed the subject quickly. . . “ or “I’ve notice that in all of our discussions, you have never talked about your romantic (sexual, passionate) life. Is this an area you would like us to explore?”
Another important function of psychotherapy, also present in the above example, is normalizing thoughts and feelings which the client fears are uniquely perverse or dirty. Letting clients know that sexual fantasies are permissible, and can be discussed, can be very liberating. This is an area where psycho-education can be a valuable tool for alleviating distress, worry and self-disgust. Clients benefit from knowing that flirtation, masturbation, sexual activity and sexual fantasy are all normal experiences. Even simply revealing the fact that people experience sexual longings at any age can relieve the worries of some seniors.
Offering Informed Advice
Some older clients need more detailed information about sexual functioning and bodily changes. Explaining to a 70-year-old married man that his wife’s inability to provide her own sexual lubrication was not a reflection of a waning desire for him, but was a result of hormonal changes related to aging, served to restore his confidence and lust for his life partner. Many an older man needs reassurance that the increased time it takes him to achieve an erection does not indicate the emergence of impotence. Rather, it is simply related to age and is counterbalanced by an increase in the time it takes to achieve orgasm, a phenomenon that can make him an even more desirable lover.
Avoiding Value Judgments and Prejudice
It is particularly important for therapists to be aware of their own ageist prejudices before dealing with older clients. The therapist’s blank or horrified expression, slip of the tongue or even hesitation at an important moment can convey to the client that an exploration of their sexual concerns is not welcome in the consulting room. Consultation with a supervisor, analyst or at the very least, a frank discussion with a colleague can help a therapist prepare to tackle these topics more comfortably and easily.
When the client is in a facility or is being taken care of by others, therapists can be particularly helpful in dealing with the prejudices and negative responses of the client’s caretakers, aides, and children.
Conclusion
Psychologists have a unique role in helping seniors to understand their continuing sexual needs and find ways to meet them in a fulfilling manner. The interaction of biological, social and psychological factors in sexual concerns and dysfunction means that the therapist plays an educative as well as therapeutic role in dealing with sexuality in seniors (Nordhus, 2005). Of sexual experience in the later years, Nordhus (2005) writes “When the allegro molto is impossible, an andante can be a satisfactory alternative . . . . ”(p. 145). We, as therapists, can help our clients to create that powerful and passionate music.
(reference available by request)
The Role of the Psychologist in Exploring Sexual Issues with Seniors
Raising and Exploring the Issue of Sexuality
Until recently, books on therapy with seniors barely mentioned the issue of sexuality except in the context of transference and acting out. There was little or no recognition or discussion of the importance to older people of maintaining sexuality in one’s life. While this silence is lifting, there are still few resources for clinicians on the subject, and even fewer when dealing with special groups: unmarried partners, gay and lesbian seniors and long-term married partners (Hillman, 2000). Psychologists, like anyone else, are prone to stereotyping and ageism. In this section I will discuss specific ways that psychologists can be helpful to seniors who have sexual interests and concerns.