One of the most poignant moments for me as I watched the epic Roots on television was the scene in which Chicken George was reunited with his wife after many years separation. Both had aged consider- ably and his wife was afraid she was no longer desirable. He allayed her fears by caressing her and rolling over on her. The camera then cut away. Not only did this scene depict affection between two elderly people, it also clearly suggested that sexual intercourse would follow. I cannot think of any other television show or film that I have seen that has even subtly indicated a sexual relationship involving the aged. Perhaps this scene was acceptable because younger performers portrayed an elderly couple. Awareness of sex in the aged has lagged far beyond the so-called sexual revolution.
Silence around geriatric sexuality persists in nursing literature despite the acknowledgment of sexuality as a legitimate nursing concern. This article deals with sexuality and aging-the physiologic capacity, oppor- tunity, and interest in the geriatric population for sexuality.
Aging modifies the body organs associated with sexual response. In women, the thin, atrophic vagina decreases its ability to lubricate and expand. This decreased lubrication can predispose to urethral irrita- tion, resulting in the urge to urinate during or after coitus. Diminished lubrication can also cause uncom- fortable penetration. Another disturbing change that may occur in aging women is painful uterine contractions with organism. Some loss of elasticity in breast tissue occurs with aging so that the vaso- congestive effect of increased breast size is not evident, while the nipple response remains intact. General muscle tension elevation decreases with age but the clitoral response pattern is the same as with younger women. Generally the intensity of physiologic reaction and duration of anatomic response to effective sexual stimulation are reduced, but the aging female is fully capable of sexual performance at orgasmic response levels.1
So women do not lose their orgasmic potentiality; their main problem may be diminshed lubrication during intercourse. However, the few aging women observed by Masters and Johnson who have immediate vaginal lubrication as opposed to the delayed and decreased lubrication usually associated with aging had maintained active sexual connections once or twice a week throughout their mature lives. Postmenopausal women who experienced infrequent coition-once a month or less-and who do not masturbate regularly have difficulty in accommodating the penis during one of their rare exposures to coition. So Masters and Johnson conclude that regular sexual expressions for the aging woman is important for maintained sexual capacity and effective sexual performance.
With the aging male, the size and firmness of the testes diminish and they do not elevate to the same degree. The seminiferous tubules thicken and a degenerative process may inhibit sperm production.2 The older man is slower to erect, to mount, and to ejaculate. The refractory period lengthens so that many men in their late 50's cannot develop penile erection for 12 to 24 hours after ejaculation. Penile erection may be maintained for extended periods of time without ejaculation. The man over 60 experiences decreased ejaculatory force and pressure which may decrease sensual experience.1 However^ Pfeiffer3 believes that these changes do not need to contribute substantially to diminution of satisfactory sexual expression in aging men.
The most important factor for the aging male in the maintenance of effective sexuality is the consistency of active sexual expression. Those men in Masters and Johnson's geriatric sample who were currently interested in relatively high levels of sexual expression had reported similar activity from younger years.1
Pfeiffer's3 research at the Study of Aging and Human Development indicates that:
Approximately 80 percent of aging men (average age 68 years) continue to be interested in sex.. .About 70 percent of elderly men still are regularly sexually active at age 68 but by the time they reach 78 the proportion has declined to about 25 percent.
In some instances, there was even an increase in sexual expression over a ten year period. His study also found individuals sexually active in every decade up to 90 through 100.
West's4 clinical experiences at a rural nursing home support Pfeiffer's research. Admission forms at the nursing home did not include a sexual history until a troubled 82-year-old man challenged:
You forgot lo ask about my sex life. Doc. and ibis is important to me. I'm having some problems ha tel y, and maybe you can help. Lately I'm having trouble keeping an erec tion for more than five minutes, and it bothers me.
After including a sexual history, he learned valuable information. Most of the women expressed a desire for sex, providing it met their moral standards. About half the men had little or no sexual desire, but the other half were still interested, although many had not had opportunities to test their functioning ability.
This suggests that many elderly people are physiologically capable and furthermore, desirous of sexual contact. Most elderly who do partake in sexual activity have one common denominator-regular contact in " previous years. Those individuals who had been highly interested and sexually active in their younger years have greater likelihood of continued sexual expression in their later years. In talking about the male capacity for erection, Downey5 viewed this idea from a negative point of view when he flippantly said, "If your don't use it, you'll lose it."
What does this mean for those individuals who did not maintain regular sexual contact for one reason or another and are now interested in sexual expression? Most research has been limited to coitus. This is only one aspect of sexual expression. A sense of intimacy, touch, closeness of bodies, and emotional rapport are all important for satisfaction in a relationship with another. This aspect of sexual expression is more difficult to evaluate empirically, but is just as, if not more important, than actual physical orgasm or intercourse. Although the senses of touch, smell, taste, and hearing are diminished with age, age is really no barrier for most of the nongenital expressions of love- caressing, touching, cuddling, and embracing.
Despite clear indications that sexual expression is an integral component of life for many aged, a myth prevails that sex stops at 60 or some other predetermined age. The elderly themselves, victims of may popular agist beliefs, have been acculturated through social pressures into believing that sex is somehow inappropriate for them. The thought of old people enjoying the physical expression of sex has become the object of ridicule. West reports showing pictures of an elderly couple kissing to a group of medical students and being met with boos and whistles. The audience had been comfortable with young people showing love but could not accept the elderly couple expressing their affection similarly.5
One origin for this widespread discomfort with geriatric sexuality may be the long-standing religious emphasis on procreation as the primary purpose of sexual intercourse. Once procreation is no longer a possibility, then intercourse somehow becomes wrong. The increased tolerance for male sexuality in old age as compared to female sexuality supports this position.
A short time ago, as part of a homily on family togetherness, a priest was relating a story about a recently widowed 80-year-old woman. She told the priest that her husband's last words to her were that she was more beautiful at that moment than when they had first met. Such a moving thought! But the priest had his own interpretation: "Of course she was so old that he couldn't have meant physical beauty." This «· an excellent example of benevolent but prejudicial interpretations others place on the elderly. My own inclination would be that in all ways, physical included, this woman was more beautiful to her dying husband than when they had first met. West emphasizes that for many old people love and sex go together and without this union neither love nor sex can be truly gratifying.5
Another facet of this denial of sexuality to the aged may be the difficulties children have in accepting parental sexual activities. Sons and daughters do not expect or anticipate the sexual needs of their aging parents and may constrict parental sexual expression through their lack of provision for privacy in living arrangements.
A combination of factors make the plight of single elderly women even more difficult than that of elderly men. Men tend to marry women younger than themselves and women live longer than men. Consequently, women live an average of 12 years longer than their husbands. At age 65 there are 129 women for every 100 men; by age 75 the ratio is 156 women for every 100 men. Pfeiffer3 demonstrates the imbalance by describing one housing project for the elderly:
The residents were 375 people aged 65 or older-75 men and 300 women, for a ratio of 400:100. But the story does not end there. Seventy-three of these men were married; only 2 were unmarried. That leaves 2 available men for 227 women. Thus although biology may not limit the sexual capabilities of aging women it does restrict their opportunities for sexual expression through the limits biology sets on the survival of males.
Implications of this imbalance on the sexual lives of single elderly women is even further complicated by statistics on marital status and sexual expression. As far as men are concerned, marital status makes no difference in the frequency of sexual expression. On the other hand, for women, marital status seems to make all the difference. Very few unmarried women reported any degree of regular sexual activity in later years. The primary deterrent to continued sexual activity for many women was the lack of a socially sanctioned sexual partner. Women seem to be caught in the double standard again. It is socially sanctioned for a man to marry someone years younger, yet older women, despite the fact that they live much longer, are not considered attractive or desirable to younger men. And men, who are usually married in old age, can still partake in sexual activity without the moral sanction of marriage.
Other research introduces yet another factor-most married women who had ceased to have sexual relations, did so because of spouses' incapacity, whereas married men ceased to have sexual relations generally because of personal incapability.8 For these many reasons, elderly women seem to get short changed in their sexual lives. The vacuum in this one area of experience compounds the loneliness, loss of companionship, and feelings of unattractiveness many women experience.
Current knowledge about the interest, opportunity, and physiologic capacity for sexuality in the geriatric population should be used by all nurses working with them. First, sexuality should be considered a potentially important component of daily living for the elderly. Health histories should incorporate a sexual history to include this relevant information. Respect should be given to the individual preference no matter what the life style or sexual preference. Professionals must be cautious, once recognizing the sexual needs of many elderly, not to overreact and press their own attitudes of appropriate sexual activity on individuals who are content with their abstinence.
The results of physiologic studies on changes in sexual response with aging should be employed when counseling the aged who are not satisfied with their present sexual response. For example, Masters and Johnson1 illustrate that men, who are not worried that they cannot run around the block as they could 40 or 50 years ago, become concerned the minute it occurs to them that they are achieving an erection at a slower rate. They should be counseled that they will take longer to achieve erection and will experience a decrease in ejaculatory volume and pressure, but be reassured that this is a normal response and it does not mean they will lose all capacity. The fear of impotency is a central concern, and should never be dismissed as a necessary development with aging.
In addition, discussion could be centered around the importance of extragenital forms of/contact, such as caressing, touching, and finding ways of pleasuring self and partner. The physical act of orgasm is not essential for sexual satisfaction. Since all the research clearly indicates the best way to achieve sexual potential in old age is through continual use in earlier years, health professionals have a responsibility to provide anticipatory guidance in these areas. Undoubtedly, this is a delicate and sensitive issue. It would seem crass to say to a woman in her 50's, who is not now having regular sexual contact, "You'd better have sex if you don't want diminished function later on." But it may be appropriate to tell her that studies show that although women generally maintain orgasmic capacity throughout their lives, women who have continued, regular, sexual contact respond easier sexually than those without contact. Masturbation could be mentioned as one way to maintain sexual function.
Since some men do lose their orgasmic potential with age, they should be told that the best insurance for potency and sexual interest in old age is continued, regular sexual contact in previous years.
Sensitivity to the problems of geriatric sexuality dictates that nursing homes and extended care facilities provide privacy to the aged. Litigation may be the initial stimulus. Downey5 believes that it would be possible to sue a nursing home not allowing sexual activity for "compromising civil rights." He believes it would be a good case; how can nursing homes knowingly deny to aged patients, "something which could hold off infirmity, stimulate mental processes, enhance self images and probably extend their lives?" Just to introduce such legislation would stimulate an awareness of the issue. Before such measures are necessary, efforts should be made now to accommodate married couples and unmarried partners into rooms with double beds. Couples should not have to worry about people barging in-closed doors should be respected.
Health care professionals have a responsibility to respect all forms of sexual expression among consenting adults. I keep thinking of an elderly man who was in the hospital when I was a nursing student 10 years ago. Staff and students were aware of his regular masturbation, but found this a source of amusement and jokes rather than accepting this as one of his needs. Part of my reaction may have been due to my own sexual confusion at the time. In 10 years, nursing and myself have changed. Sexual expression is no longer a source of "dirty" jokes but a valid nursing concern. But even people who accept heterosexual contact as "straight" consider other forms of contact, such as autoeroticism and homosexuality, as deviant. The predominance of elderly women over men precludes the opportunity for heterosexual contact for many. Masturbation may be the only outlet for a partnerless woman, and homosexual contact may be the only way or preferred way for many women to receive the closeness, fondling, and caressing they crave.
Geriatric sexuality has been ignored for a long time. To consider the sexual needs of the elderly isolated from their myriad of other needs creates an artificiality around this issue. I want to emphasize that sexuality is only one aspect in the lives of the elderly. Its importance varies with the individual.Individuals should not be denied the opportunity for experiencing their sexuality and sensuality because of age. Recognition of the sexual needs of many elderly individuals is the first step in providing opportunity for its expression.
- 1. Masters W, Johnson V: Human Sexual Response. Boston, Little, Brown and Co, 1966.
- 2. McCary J: Sexual advantages of middle-aged men. Med Aspects Human Sexuality 7(12): 139-151, 1973.
- 3. Pfeiffer ?: Sexuality in thé aging individual. J Am Geriatr Soc 22:481-484. 1974.
- 4. West N: Sex in geriatrics: Myth or miracle. J Am Geriatr Soc 23:551-552, 1975.
- 5. Downey G: The next patient right-sex in the nursing homes. Mod Health Care l<6):56-59, 1974.
- 6. Kent S: Continued sexual activity depends on health and the availability of a partner. Geriatr 11:142-143, 1975.
- Photographs are from an A-V presentation Aging and Sexuality: A Physiological Approach, Gerontology Program, University of Nebraska. Creator-photographer: Diane Abercrombie-Estes, RN, BSN, Archbishop Bergan Mercy Hospital, Omaha, Nebraska.