In the early part of this century Victorian ideas of human relationships were the underpinnings of the scant literature on sexual activity and sexuality. Even the relatively contemporary thinking of Havelock Ellis in the late 1920s retained the belief that the purpose of sex was for procreation and motherhood, was a woman's primary role in life.1 Since fewer women and men than today lived many years beyond childbearing age, there was little incentive to challenge these beliefs or to give much thought to aging sexuality. It made sense, in terms of "historical relativity" (explaining social behavior within the context of a particular period of historical time2), to associate all sexuality with marriage and marriage with procreation functions.
The increase in the number and ages of older adults in our society is well documented. We can now expect a record 32 million older Americans by the year 2000 with current estimated life expectancies for males and females of 70.3 and 77.9 years respectively.3 These increases in size and longevity of our older population are causing American society to rethink and redefine long-standing cultural biases about aging sexuality and the older adult years. Now, more than ever before, nurses may find themselves the primary information/education source for older, healthier, sexually active married, unmarried, and remarried older adults.
In 1948 and 1953 two history-making reports on human male and female sexual behavior were published by an entomologist specializing in gall wasps.4 Dr. Alfred Kinsey based his reports on the verbal sexual histories of more than 10,000 white males and females. Perhaps the greatest criticism of Kinsey's work is the possible selection bias in his sample of voluntary respondents. Among the most obvious concerns of the representativeness of the Kinsey sample are the exclusion of nonwhite respondents in the published reports, the nonrandom selection procedures, over-representation of individuals in the northeastern United States, and the relatively small portion of the data set reporting on the aging adult. Despite what appear to be major methodological shortcomings, surveys completed in the United States since his published works tend to confirm or very closely agree with the key Kinsey findings.4
Kinsey's first volume on human sexual behavior addressed the male.5 Throughout the volume Kinsey pointed to declining sexual activity as a result of numerous psychological factors such as fatigue, familiar contacts, and old techniques rather than as a solely agerelated physiological event. Kinsey also found two physiological effects of aging most prevalent in his sample: decreased speed in reaching full erection and decline in length of time over which erection could be maintained.
Five years after publishing the volume on male sexual behavior Kinsey published a volume on female sexuality.6 Contrary to popular beliefs about female frigidity, Kinsey reported a strong interest in sexual relations by women which actually increased with age. Many women (65%) reported reaching orgasm in their late 50s. Most of Kinsey's females maintained an interest in sexual relations until their 60s and then experienced a steady decline in frequency of marital coitus. Kinsey concluded that the decline of sexual activity must be related to aging husbands, rather than a decline in the desire for sexual relations, since in American society women usually marry men approximately four years their senior.
Masters and Johnson were the first researchers to publish a reference on the physiology of the human sexual response.7 In subsequent years of research on aging sexuality, they have been joined by several other sex researchers in providing insight into our aging population's sexual responsiveness.
However, even today. American society does not totally allow aging adults the freedom to openly express their sexuality. Both aging males and females can be shamed into hiding their sexuality or curiosity about normal physiologic changes in sexual expression to the point where they begin to see themselves as perverse or ultimately as sexless individuals.8,9
Most of the concerns about sexual inadequacy in the aging female are primarily related to normal vaginal alterations which occur secondary to steroid changes during menopause. Opportunity for regular coital activity in the aging female will usually promote a higher capacity for sexual performance than in females who do not have similar coital opportunity.
Yet, even among regularly sexually active older women, common physical changes after menopause may cause symptoms of painful penetration, vaginal burning, pelvic aching, or irritation in urination lasting up to 36 hours after coitus.7 Many women who are faced with the situation of an older or infirmed spouse may resort to masturbatory practices to relieve sexual tensions. Masturbation is not, however, an adequate substitution for counteracting the effects of sex-steroid deprivation on the vagina.10,11
Unlike the aging female, most males in sound physical and mental health can expect adequate sexual performance beyond 80 years of age. When alterations in male responsive ability do occur, they generally fall within one or more of the following categories:
1 . monotony of a repetitious sexual relationship;
2. preoccupation with career or eco- . nomic pursuits;
3. mental or physical fatigue;
4. overindulgence in food or drink;
5. physical and mental infirmities of either self or spouse; and
6. fear of failure in sexual performance.7
At least one study suggested the importance of socioeconomic status on sexuality in older adulthood. In a study of 188 high socioeconomic males, ages 60 through 79 who resided in the Washington-Baltimore metropolitan area, Martin found that, in spite of apparent good health, over one third of 60- to 79year-old respondents reported no more than six sexual events within the year.12 Most of the subjects who were less than fully potent regarded their marriages as highly successful and their wives as physically attractive. According to the study findings, these men remained relatively sexually inactive while also feeling free from performance anxiety, and free of feelings of sexual deprivation and loss of self-esteem.
Persons over age 65 in 1980 averaged 1.1 episodes of disability from acute conditions (lasting less than three months and involving medical attention or activity restriction). During this same year, the aging adult averaged 10.6 days of restricted activity because of acute conditions, four days of which were spent in bed. Nearly half of all noninstitutionalized persons aged 65 and over were reported to have a chronic health condition that limited their activity for about 5'/2 weeks, with about two weeks spent in bed. In addition, one in four persons in this age group spent some time in the hospital and 17 out of 100 sustained an accidental injury during the year. ,3 Finally, the National Cancer for Health Statistics reported the leading chronic conditions in the 1981 population of men and women age 65 and over were arthritis and hypertensive disease.14 With a large portion of the elderly population receiving antihypertensives, the two most common side effects were depression and impotence which pose a serious problem to aging sexuality. These statistics suggest that almost universally every surviving spouse of an aged marriage has had to live with coital continence for some period of time before or following the death of the spouse.
The widower's syndrome, reported by Masters and Johnson as sexual continence by a man in his late 50s or beyond, frequently follows an extended illness and death of the spouse.11 The male simply cannot achieve or maintain a functional erection. The widow's syndrome is the female counterpart of the widower's syndrome. Typically, the aging female is contending with voluntary or involuntary sexual continence compounded by postmenopause. As sexual continence is prolonged, the walls of the vagina become atrophic, the vaginal barrel constricts, the vaginal outlet constricts, and the major and minor labia are thinned.11 Clearly the aging adult male and female cannot easily recover from prolonged lack of sexual relations.
On any one day 5% of the nation's older adults reside in a nursing home. In reality, however, current estimates of the lifetime risk of some period of institutionalization for our nation's elders actually exceeds 35%.15
In 1978, Kaas reported a study dealing with differences between elderly nursing home residents and nursing staff on attitudes toward sexual expression of the elderly.8 Utilizing 85 residents age 65 years and older from five nursing homes in the Detroit area, several important points were raised by the residents. Although the research of aging sexuality up to this time was generally very positive, the institutionalized residents in the study said they did not feel sexually attractive. In addition, these residents said they would not enjoy sexual activity if they had a willing partner.
Although the residents felt that sex was normal, most residents felt it was needed more for older women than older men, the double standard in reverse! Also, the residents saw lack of privacy in the nursing home as a deterrent to sexual expression.
As the residents in the study reported, if one does not feel sexually attractive, the desire for a sexual relationship is usually absent. As more and more older adults spend some portion of their lives recovering in a nursing home, perhaps posthospitalization, healthcare providers must attend to these perceived losses of sexual attractiveness and self-esteem.
Sexuality is not, of course, entirely equated with coitus. The older adult, like people at any age, has strong emotional needs which may be met by holding, touching, and closeness without intercourse. Touching of two older adults can bring sensual pleasure with no further goal than enjoyment of the physical presence of another human being. In addition to or in the absence of coitus, touching may satisfy the need for sexual expression of aging adults.
As the next section will show, many authors suggest that contactual relationships, more so than sexual relationships, are án important force in bringing aging individuals together in their later years.
Remarriage in Older Adulthood
When an individual has experienced a gratifying relationship in a marriage, there is inevitable pain and grief when one partner dies. Most survivors eventually feel free to start life again and even to contemplate remarriage.20 As mentioned earlier, when there were only a few persons living to old age, love and marriage in later life weren't given much significance. Today, however, millions of older men and women are in remarriages and are finding that there are no models for these relationships.16
Early indicators of the emerging sexuality of older senior singles suggest a sex ethic similar to other adult age groups in America. Young and old adults generally view sex in a liberal, romantic way. 16 The emerging trend is for sexual activity to be viewed as more than a procreative function and for relationships to include companionship as well as coitus.
The desire to share an intimate relationship with a new marriage partner is not, unfortunately, always enough to have the dream of remarriage come true. In 1970, there were more than 6 million widows and IYz million widowers in the United States. From 1974 to 1985 , the number of single females in the United States was expected to rise by 3 million and single men by about 700,000. 17
Since women who reach age 65 live about seven years longer than men at the same age and since 80% of American women reach age 65 versus only 65% of the males, there are about five times as many eligible widows as widowers. I7 A man who wants to remarry can usually find a willing woman either in his age group or younger. A woman who wants to remarry may not be so successful.
More older people are marrying today because there are greater numbers of older people. However, the propensity of older people to marry has not changed over time. Social norms ordain that men wed brides younger than themselves, a custom which expands the number of potential partners for older men and severely restricts marital choices for older women.18
Several consequences of widowhood also can influence a person's desire for another mate. Among these reported by Cleveland and Gianturco19 are:
1 . lack of companionship;
2. less economic security;
3. high morbidity and mortality compared to married counterparts; and
4. poor social adaptation due to isolation and loneliness.
The opportunity to meet and court prospective mates is an important selective factor in remarriage. Data on courtship and remarriage of older adults are scarce. Jacobs and Vinick interviewed 24 couples who had been married between two and six years in which at least one spouse was 65 years or older and in which both spouses had been married previously. ,7 In this small sample they found that the length of time between the death of a spouse and the subsequent remarriage varies between men and women. Two years was the shortest time living alone for the women in the study; nearly half lived alone ten years or longer. The men, on the other hand, remarried much sooner. More than half of the men remarried in a year or less. Similar findings have been reported in an earlier study at the University of Connecticut on 100 older couples.20 In this earlier study, widowers seldom waited more than a year or two before remarrying, while widows frequently waited several years.
It seems obvious that the issue of more eligible widows for every eligible widower is a factor in the length of time men and women remain alone after the death of a spouse. The "numerical disparity" between the sexes is compounded by the fact that most single elders depend on ordinary methods to meet potential mates.
Many couples who marry knew each other for many years during their previous marriages as neighbors or members of the same church, or were introduced by a mutual friend or relative. Meetings at adult functions are also a source of meeting a potential mate but not as often as prior relationships.17,20 At least one author has suggested broadening one's mating network to include newspaper advertisements, computer dating, and video services.21 While this may not be attractive to today's elderly singles, elders of the near future may find innovative dating devices very attractive.
Children of the dating couple are sometimes resistant to the idea that their parents would be comfortable in a relationship with someone other than the dead parent. Many times a concern about inheritance, should the parent remarry, causes some concern of the children. Most often, however, children are supportive; perhaps because they feel relieved of the care and companionship requirements of the widowed parent.22,23
Men and women ultimately decide to remarry late in life for a variety of reasons. Companionship is by far the major reason given for remarriage. 20iiThe elderly widowed of today are in better health, have greater financial security, and greater mobility than the previous aging cohorts. When faced with the options of living the remainder of their years alone, living with children, moving into congregate living or remarrying, the choice of remarrying appeals to most elders who are given the opportunity to make such a choice.20
Obviously love and companionship are not the objects of all second marriages. Especially for the elderly woman, financial security may be a factor in the decision to remarry. The male's incentive to remarry may be for a housekeeper or a nurse, if his health is declining. In general, widows and widowers who looked for a housekeeper, more income, or a nurse in the remarriage do not have as good a chance for happiness as those who selected a mate based on companionship and love.20
Once the aging couple decides to remarry, data indicate that most couples bow to public opinion to the extent of having a simple ceremony.20 The second ceremony is usually more personal than the first but with less tradition and pomp. The guests are usually close friends and family. Reports conflict over the type of ceremony and choice of honeymoon with McKain20 citing a preference for a civil ceremony with no honeymoon while Treas and Van Hilst18 report a preference for a religious remarriage with a honeymoon.
When at least one partner in a remarriage is a widowed person, Bernard reported three major areas of potential difficulty for marital adjustment:
1. the tendency of the widowed spouse to idealize the deceased mate.
2. the knowledge of the new spouse that the partner's first marriage was not terminated voluntarily.
3. the feelings of friends and relatives that the new spouse is an intruder.24
Despite the areas of potential conflict, most older remarriages report a high success rate. Contrary to popular thinking on marital happiness, older couples put a premium on calmness and holding back angry feelings rather than open, free expression of negative feelings.17 Older people seem to bring the important ingrethent of experience to a successful marriage. In general, success in remarriage has five major variables:20
1 . widows and widowers who knew each other well usually had a successful marriage;
2. remarriages which had approval of friends and relatives had greater chance for success than those which did not;
3. those who had adjusted to role changes that accompany aging usually had successful remarriages;
4. those who owned a house but did not live in it after remarriage tended to have successful remarriages; and
5. couples with sufficient income were more likely to have a successful remarriage.
As the number of older Americans increases into the next century, the amount of remarriages in older adulthood will probably increase even though the proportion of remarriages in the age group is not expected to change from current rates. American society has traditionally equated marriage with procreation and has been reluctant to sanction the union of partners of any age for any other purpose.
Sex researchers in the last 20 years have demonstrated the value of aging sexuality as a desirable component of successful aging. Remarriage in later life can be a positive and feasible alternative to being alone following the death of a spouse in older adulthood.
One issue of aging sexuality that emerged in this literature review was the need for understanding other elements of human sexuality including touch, kissing, and close warm contact. It would seem that greater attention to contactual stimulation needs for aging couples is in order.
So much of today's knowledge of aging sexuality and sexual activity was developed on a very small group of subjects almost two decades ago. This research represents a different aging cohort than we see today. Yet, these data are cited over and over again as though the findings can be generalized to all older adults indefinitely.
There are numerous research questions to be generated from this literature and our daily interactions as healthcare providers with older individuals and couples. For example, what about the issue of diminished sexual attractiveness in institutionalized elders in the Kaas study? How are we addressing the lack of privacy issue in nursing homes?
How can we most effectively counsel or support the sexually continent spouse of a chronically ill, disabled mate? What expectations of older adults' sexuality do we impose on our elderly clients by our actions or attitudes? Are we as tuned in to the family dynamics of newly wed older adults as we are to more traditional family dynamics in the hospital? In the community? In the nursing home? Each of us in our own clinical setting can probably generate many more questions in need of additional research.
- 1. Ellis H: Man and Woman. New York, Houghton Mifflin Co, 1929.
- 2. Hall E: A conversation with Erik Erikson. Psychology Today 1983; 17(6):22-30.
- 3. US Department of Health and Human Services: Annual summary of births, deaths, marriages and divorce: United States, 1981. Monthly Vital Statistics Report. December 20, 1982, 30(13).
- 4. Brecher E: The Sex Researchers. San Francisco, Specific Press, 1979.
- 5. Kinsey A, Pomeroy W, Martin C: Sexual Behavior in the Human Male. Philadelphia, WB Saunders Co, 1948.
- 6. Kinsey A, Pomeroy W, Martin C: Sexual Behavior in the Human Female. Philadelphia. WB Saunders Co, 1953.
- 7. Masters W, Johnson V: Human Sexual Response. Boston. Little, Brown and Co, 1966.
- 8. Kaas M: Sexual expression of the elderly in nursing homes. The Gerontologist 1978; 18(4):372-378.
- 9. Stanford D: All about sex . . . after middle age. American J Nurs 1977; 77(4):608-6il.
- 10. Bachmann G, Leiblum S: Sexual expression in menopausal women. Medical Aspects of Human Sexuality 1981; 15(10):96B-96H.
- 11. Masters W, Johnson V: Sex and the aging process. Medical Aspects of Human Sexuality 1982; 16(6)40-57.
- 12. Martin C: Factors affecting sexual functioning in 60-79 year old married males. Archives of Sexual Behavior 1981; l05):399-420.
- 13. Metropolitan Life Foundation. Health of the elderly. Statistical Bulletin 1982; 63(l):3-5.
- 14. National Center for Health Statistics, 1981 National Ambulatory Medical Care Survey, unpublished.
- 15. Liang J, Tu E: Estimating lifetime risk of nursing home residency: A further note. The Gerontologist 1986; 26(5):560-563.
- 16. Peterson J, Payne B: Love in the Later Years. New York, Association Press, 1975.
- 17. Jacobs R, Vinick B: Re-engagement in Later Life: Re-employment and Remarriage. Stamford, Conn, Greylock Publishers. 1979.
- 18. Treas J, VanHilst A: Marriage and remarriage rates among older Americans. The Gerontologist 1976; 16(2):132-136.
- 19. Cleveland W, Gianturco D: Remarriage probability after widowhood: A retrospective method. J Gerontol 1976; 31(I):99-I03.
- 20. Mc K ai ? W: A new look at older marriages. The Family Coordinator 1972; 21(l):6l-69.
- 21. Jedlicka D: Formal mate selection networks in the United States. Family Relations 1980; 29(2): 199-203.
- 22. Vinick B: Remarriage by the elderly. Medical Aspects of Human Sexuality 1983; i7(10):1 11-116.
- 23. Pattison EM: When an adult's parent remarries. Medical Aspects of Human Sexuality 1983; 17(5):60B-60U.
- 24. Bernard J: Remarriage. New York, Russell and Russell. 1971.