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September/October 2019
Sex and the Older Adult — No One Wants to Talk About It Sex remains an important aspect of life for many older adults, even very late in life. Despite this, research suggests that there’s little communication between clinicians and older adults about sex: In a survey of older adults in the New England Journal of Medicine, only 38% of men and 22% of women reported discussing sex with a physician since reaching the age of 50.1 This lack of communication may partly be due to the fact that patients aren’t likely to bring up sex. But clinicians, too, are prone to overlooking the topic, says Lindsay Wilson, MD, MPH, an assistant clinical professor in the division of geriatric medicine at the University of North Carolina Chapel Hill School of Medicine. “We don’t spend a lot of time on this. We probably don’t spend enough time on any patient population, younger people included. But older people in particular are probably not asked as often as they should be,” Wilson says. Barriers to Discussing Sex Beyond this discomfort, lack of time during office visits is also a real issue. “You have 15 minutes with your patient, and you are supposed to talk about diabetes, and their hypertension, and their constipation, and then where do you fit in questions about their sex life?” Sewell asks. Prevalence of Sexual Activity In fact, older adults often go to great lengths in order to maintain a sex life, according to Wilson. She recalls, for instance, a patient in his 80s who was on chemotherapy but still trying to work on a sexual relationship. “There are people that just don’t perceive the barriers that we would think would be there,” Wilson says. “The comorbidities or medications or erectile dysfunction—people are trying to overcome those and stay sexually active.” Given that a significant percentage of older adults either are sexually active or would like to be, Wilson encourages clinicians to make sexual health a priority as far as possible. “Not all older people are engaging in sexual activity, but those that are are being underserved by clinicians and not getting enough advice or preventive measures or recommendations,” Wilson says. “So I think it’s very important that as practitioners we develop comfort in talking about it and bringing it up with patients.” Significant Sexual Health Concerns Physically, women face a decrease in circulating estrogen after menopause, which sets them up for vaginal dryness and increases the likelihood of discomfort and pain during intercourse. For men, erectile dysfunction is increasingly common with age. The fact that older adults tend to take an increasing number of medications as they age can make the situation far worse. In Sewell’s field of psychiatry, for example, there’s a spectrum of medicines useful for treating depression. Some of these medications don’t have an impact on sexual function, but others are famous for their toxic effect on patients’ sex lives, Sewell says. The same is true with medications to treat an array of other conditions. Physical capacity also changes with age. While sexual activity is important throughout the lifespan, the athleticism of sexual encounters diminishes. Older adults likely don’t have the cardiac reserve, flexible joints, or other physical characteristics that would allow for athletic sex,” Sewell says. At some point, couples may cease coitus, and sexual activity may consist of merely going to bed, cuddling, and exploring each other’s bodies tactilely. But even if the nature of sexual activity changes, its value often remains the same. “[Older adults] don’t always have to have an orgasm and they don’t always have to have intercourse, but it’s just as valuable to them as it might be for the younger adult who would say, ‘Oh yes, I must have intercourse,’” Sewell says. “The opportunity for physical closeness and emotional closeness is still there.” As for psychosocial changes that occur with age, widowhood is a significant issue. Many older adults who have lost a spouse may wish to meet a new partner, but doing so is often a struggle. Importantly, Sewell says, there’s some indication that single older adults are increasingly likely to meet their needs for companionship and sex by seeking “friends with benefits” instead of opting for closed, committed relationships. In a survey of older adult sexual behavior from researchers at Indiana University, 22.5% of men older than 50 said their last sexual encounter was with a friend or new acquaintance (for women over 50, the figure was 13.5%).3 “Things change when you’re older, because you don’t have quite that same spectrum of responsibilities and duties that you may have during the middle part of your life,” Sewell says. Therefore, older adults may not feel the same need of a committed partner, and given the challenge of blending two families, it may be that older people don’t always want the complication of a relationship. One issue that does not change with age is the need for discussions surrounding safe sex. Older adults may assume they no longer have a need to use protection during intercourse once female partners have reached menopause and pregnancy is no longer an issue. This may explain why rates of condom usage are lowest among adults older than 40.4 But if pregnancy is not an issue in older age, sexually transmitted diseases (STDs) are. Although new STD infections are far more common among younger adults than older adults, the rate of new STD infections (including gonorrhea, chlamydia, and HIV) has increased dramatically in recent years among adults age 65 and older.5 Starting the Conversation Don’t discount the value of your expertise. It may seem that older patients already have enough experience with sex that they would have nothing to learn from a clinician, especially if the clinician is young. But Sewell argues that physicians should move past this worry. “We are the ones who are trained medically,” he says. Patients aren’t innately aware of how to deal with erectile dysfunction or dyspareunia, he adds, and they need clinical expertise in addressing these issues. Take the responsibility for bringing up the conversation. Individuals who are currently in their 80s grew up in an era in which discussion of sex was discouraged. In addition, older adults are aware of the stereotypes surrounding sex in aging (such as the stereotype of the “cougar” or the “dirty old man”) and may fear being misconstrued if they speak up. Therefore, clinicians have to be willing to raise the subject of sex. “If we’re waiting for the older adult to have the courage or the wherewithal to introduce these topics, we’re making a mistake,” Sewell says. On the flip side, according to Wilson, patients are often quite willing to talk if a clinician simply broaches the topic of sex. “With a lot of older people, once you open it up to discussion, they are very forthcoming,” she says. “They will tell you what’s going on. It’s not as difficult as I think we imagine.” Ask in the right setting. An emergency department cubicle, where the only separation between the patient and the outside world comes from a curtain, isn’t a good environment for discussing sex, Sewell says. Make sure the setting is one that ensures patient privacy. Ask at the right time. Avoid waiting until the last five minutes of an office visit; doing so suggests that you didn’t think the topic was important, and it simply doesn’t leave enough time to have a real discussion. “To do a nice job of asking an older adult about their sex life, my rule of thumb is you need to bring it up no later than the midpoint of whatever amount of time has been allotted for you to be with that patient,” Sewell says. In other words, in a 15-minute visit, raise the subject of sex by minute seven or eight. If by chance a patient happens to raise a last-minute concern at the end of a visit, don’t ignore it. Instead, indicate that you don’t want to brush over the concern too quickly and encourage the patient to schedule a follow-up visit where you’ll have plenty of time to fully discuss the issues. Ask without judgment. A question such as, “Are you sexually active?” can leave a patient feeling that they are outside the norm regardless of which way they answer. A better bet, according to Sewell, is to ask, “Have you experienced any changes in your sexual life?” Wilson occasionally asks directly about an issue such as erectile dysfunction if she has reason to think it might be a problem (for example, based on medications the patient is taking). But she, too, generally opts for a nonpresumptuous general query, such as, “Do you have sexual health questions?” Regardless of the specifics of how and when to raise sexual health conversations, the bottom line is simply to make the conversation a priority. “There are serious implications, both in terms of quality of life and patient safety, when we don’t ask older adults about their sex lives,” Sewell says. — Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.
References 2. Waite LJ, Laumann EO, Das A, Schumm LP. Sexuality: measures of partnerships, practices, attitudes, and problems in the National Social Life, Health, and Aging Study. J Gerontol B Psychol Sci Soc Sci. 2009;64(Suppl 1):i56-i66. 3. Schick V, Herbenick D, Reece M, et al. Sexual behaviors, condom use, and sexual health of Americans over 50: implications for sexual health promotion for older adults. J Sex Med. 2010;7(Suppl 5):315-329. 4. Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Condom use rates in a national probability sample of males and females ages 14 to 94 in the United States. J Sex Med. 2010;7(Suppl 5):266-276. 5. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Sexually transmitted disease surveillance 2016. https://www.cdc.gov/std/stats16/CDC_2016_STDS_Report-for508WebSep21_2017_1644.pdf. Published September 2017. |
