Human sexuality has been associated with health benefits and longevity and is increasingly being
recognized as an important aspect of quality of life throughout the lifespan. Promoting successful aging is particularly important in light of the recent
growth in the aging population, as Baby Boomers mature and life expectancies increase. Although prevalence estimates vary, Lindau et al. (2007) reported that the majority of adults older than 57 were sexually active, and 26% of adults ages 75 to
85 were sexually active. Continued study of sexuality in older adults also has important public health implications, as the Centers for Disease Control and
Prevention surveillance reports suggest that the overall proportions of older adults with HIV is increasing (
Linley, Prejean, An, Chen, & Hall, 2012).
Sexuality in older adults involves a complex
interplay between physical capacity, motivation, attitudes, opportunity for partnership, and sexual conduct (
Lindau, Laumann, Levinson, & Waite, 2003). For some, sexuality may become less important with aging, but this may not be true for the
majority. Investigating sexual health can be challenging because of the sensitive nature of questions; preconceived expectations; and varying definitions
of what individuals, cultures, and generations consider sexual activity.
Although relatively few studies explore sexual expression in community-
dwelling, healthy older adults, many studies have examined the impact of illness on sexuality. Conditions such as diabetes (Lindau et al., 2010) and joint issues have been negatively correlated with sexual activity (Bach, Mortimer, VandeWeerd, & Corvin, 2013). Urological conditions, such as overactive bladder (Coyne et al., 2011) and urinary incontinence (Hawkins et al.,
2011), are prevalent in older adult patients and can also impair sexual health. Cardiovascular and pulmonary conditions, as well as cancers,
that more commonly affect older adults, can also contribute to sexual concerns (Steinke, 2013). However,
the loss of a partner (Bach et al., 2013) and health problems may be more to blame for declining sexual
activity than disinterest.
In a landmark study of 1,956 older adults living in Washtenaw County, Michigan (i.e., Medical, Epidemiological, and Social
Aspects of Aging [MESA]), Diokno, Brown, and Herzog (1990) also found potential links between mobility
problems and urinary incontinence and the lack of sexual activity. In addition, investigators found an association between coffee intake and sexual
activity. Sexual activity was reported by 62% of 185 married women who drank coffee, and only 37.5% of the 40 women who did not drink coffee (p =
0.008). In men, non-intake of coffee was related to increased erectile difficulty (p = 0.024) (Diokno et al.,
1990). Despite real or perceived challenges, the majority of older women and men believe that sexuality has beneficial effects and is a lifelong
need (Penhollow, Young, & Denny, 2009).
Although the development and widespread marketing of
medications to treat male erectile dysfunction (ED) has increased the focus on sexuality in older adults, sexual concerns are still inconsistently
addressed, especially in older women. The extent to which urology specialists and other health care practitioners are able to evaluate for sexual concerns
may be limited by time constraints, discomfort discussing sexual issues (Price, 2009), and a general
perception that sexuality may not be as important for older adults. In one study of sexuality in adults ages 40 to 80, only 11.5% of men and 15% of women
had been asked by a doctor about possible sexual difficulties during routine visits within the past 3 years (
Laumann, Glasser, Neves, Moreira, & Global Study of Sexual Attitudes and Behaviours Investigators’ Group, 2009). Health care practitioners
may find it difficult to talk about sexuality with older adults partly because of a lack of knowledge (Gott,
Hinchliff, & Galena, 2004). Others have noted that nurses working with institutionalized older adults also have limited knowledge of
sexuality in older adults (Mahieu, Van Elssen, & Gastmans, 2011). However, one Dutch study’s
findings suggested that although continence nurses were aware of the strong association between urological complaints and sexual problems, few routinely
assessed sexual function (Bekker, Van Driel, Pelger, Lycklama à Nijeholt, & Elzevier, 2010). Therefore, a need exists for more information, and health
care providers in particular need a more complete understanding of sexuality in older adults to provide holistic, comprehensive, and high-quality care.
The purpose of the current study was to (a) explore factors that may impact sexuality and sexual expression in a population-based sample of older
heterosexual adults and (b) re-evaluate the findings of the Diokno et al. (1990) study. Therefore, the
authors of the current article designed another study of older adults in Washtenaw County, Michigan, to explore the effect of factors such as marital
status, health, mobility, urinary incontinence, caffeine and alcohol use, sexual desire, and erectile function on sexual activity in older adults.
After obtaining institutional review board approval, the authors of the current article purchased a mailing
list of 2,500 households in Washtenaw County, Michigan, from a marketing list vendor; each household had a head of household who was a least 60 years old.
The authors developed two gender-specific surveys that were based on the MESA study (, available in the online version of this article).
Demographics, medical and surgical history, health and mobility, coffee and tea intake, sexual activity, alcohol use, and urinary incontinence were
assessed in men and women; in addition, sexual desire was assessed in women, and erectile function was assessed in men. One survey for men and one survey
for women were sent to each head of household and his or her partner. Questions about sexual orientation were not included in the survey; however, the
authors anticipated that almost all respondents would be heterosexual, as only 1% to 2.3% of adults self-identify as gay or lesbian (Carpenter, 2013). Sampling only heterosexual couples would allow the authors to re-examine the previously
found link between caffeine and sexual activity in married couples (Diokno et al., 1990). Using this
method, sampling 2,500 households would yield up to 5,000 survey respondents. If only one partner completed a survey, he or she was still included in the
study. A cover letter, a study information sheet, the two surveys without any subject identifiers, and two postagepaid return envelopes were mailed to each
household. No other attempts were made to recruit study participants or contact survey respondents.
MESA study (Diokno et al., 1990), participants were considered sexually active if they responded
yes to the question: “Are you sexually active?” However, for the current study, participants were asked, “Are you sexually active? Sexual activity can
include touching and caressing, masturbation, and sexual intercourse.” Those who reported sexual activity (based on the study definition) at least once per
month were considered sexually active. Participants were also asked how much coffee and tea they typically consumed in a 24-hour period, what type of
coffee and/or tea (i.e., caffeinated or decaffeinated) they consumed, and how long they had been drinking coffee and/or tea. Other sources of caffeine,
such as soda and/or energy drinks, were not assessed. MESA participants were considered coffee drinkers if they drank at least one cup of any type of
coffee per day without specifying whether the coffee contained caffeine. Participants in the current study were categorized as coffee drinkers if they
drank at least one cup of caffeinated coffee per day for at least 1 year. Although other tea types (i.e., green tea) were assessed, to be consistent with
the MESA study, participants in both studies were labeled as tea drinkers if they consumed at least one cup of black tea per day for at least 1 year. Any
reported wine, beer, or liquor consumption was considered alcohol use.
The survey for men also
contained the validated Sexual Health Inventory for Men (SHIM; Rosen, Cappelleri, Smith, Lipsky, & Peña,
1999). The SHIM is a widely used scale with high sensitivity and specificity for screening/diagnosis of erectile dysfunction (ED). The SHIM is
scored by adding the numbers associated with each response. ED can be classified into five severity grades based on SHIM scores: no ED (22 to 25),
mild (17 to 21), mild to moderate (12 to 16), moderate (8 to 11), and severe ED (1 to 7).
The survey for women contained
the sexual desire domain of the Abbreviated Sexual Function Questionnaire (ASFQ©; Williams, Abraham,
& Symonds, 2010); however, the sexual arousal, orgasm, and pain domains were not included. Including all ASFQ domains would be important for
a comprehensive study of female sexual dysfunction, but because existing data suggest that desire is significantly associated with frequency of sexual
activity in later life (Kontula & Haavio-Mannila, 2009), only the desire domain was included. The
desire domain contains four questions about frequency of pleasurable thoughts about sex, desire for sensual touching, desire for taking part in sexual
activity, and frequency of initiating sexual activity over the past 4 weeks. Each question has five levels of responses: not at all, rarely,
sometimes, often, and very often. ASFQ scores were calculated using standardized scoring criteria. Both the ASFQ and scoring manual
are available with permission (access
The authors of the current article conducted a power analysis to test whether coffee impacted sexual activity and estimated that 124 female
survey respondents and 144 male survey respondents would be needed to achieve 80% power at a 0.05 significance level. This calculation was based on the
previous study by Diokno et al. (1990). Using response rates to prior studies (Ibrahim, Diokno, Killinger, Carrico, & Peters, 2007) as a guide, the authors estimated that sampling
2,500 households would provide up to 823 survey respondents (divided equally by gender), as well as sufficient power for the current study. Survey
responses were examined with Fisher’s exact, Pearson’s chi square (expected frequency >5), or Mantel-Haenszel tests, as well as backwards elimination
multivariable logistic regression analyses. A p value of <0.05 was considered statistically significant.
A total of 242 participants (113 women and 129 men) returned the survey. Of these 242 individuals, most were ages 60 to 74 (79%),
married (90%), White (90%), college educated (84%), retired (64%), and in good to excellent health (87%). Overall, 159 (65.7%) were sexually active, and
110 of 151 (72.9%) sexually active participants engaged in intercourse. The majority of sexually active adults (104 of 158, 65.4%) reported performing
sexual activity at least once per week. Most participants reported some caffeinated coffee or tea intake; 55% drank coffee only, 5% drank tea only, and 6%
drank both coffee and tea. However, 35% reported no coffee or tea intake. Sample characteristics stratified by age group are depicted in the Figure.
Sample characteristics by age group.
grouped survey respondents based on whether they stated they were sexually active and examined factors that may be associated with being sexually active.
Compared with adults who were not sexually active, a higher proportion of sexually active older adults were married (p = 0.0005), did not have
urinary leakage (p = 0.006), had better mobility (p = 0.0014) and health (p = 0.0003), and reported alcohol use (p = 0.007)
(Table 1). Those who were sexually active also reported higher levels of satisfaction with their
sex life (p < 0.0001). Engaging in sexual activity and having intercourse declined with increasing age (p < 0.0001) (Figure).
Comparison of Not Sexually Active and Sexually Active Study Participants
Table 1 (Continued):
Comparison of Not Sexually Active and Sexually Active Subjects
When examined by gender, similar proportions of women and men were sexually active (Table 1). Of those who were
sexually active, most women (74.6%) and men (71.4%) stated that they engaged in intercourse. When sexually active women were compared with inactive women,
and sexually active men were compared with inactive men, marital status and general health remained significantly different between groups (Table 1). Sexually active women were more likely to be taking hormones (p = 0.049), report alcohol
use (p = 0.0013), and have better ASFQ desire scores (p < 0.0001) compared with women who were not sexually active. Sexually active men
reported better erectile function (p < 0.0001) than sexually inactive men and were less likely to report erectile difficulty (p <
0.0001); however, a higher proportion used erectile aids (p = 0.012). Although urinary incontinence was reported by similar proportions of women and
men overall, only a higher proportion of sexually inactive men versus active men had urinary incontinence (p < 0.0001), as well as difficulties
with mobility (p = 0.012). When coffee and non-coffee drinkers were evaluated, no statistically significant differences were found (Table 2). Tea and non-tea drinkers, as well as those reporting any caffeine (i.e., tea and/or coffee) use,
were also similar when compared with participants who denied caffeine use.
Comparison of Non-Coffee and Coffee Drinkers
Multivariate logistic regression analyses
evaluated the effect of several variables on sexual activity, including coffee intake, tea intake, age, marital status, urinary incontinence, health
status, diabetes, alcohol use, and mobility. In women, the ASFQ desire score was added to the multivariate models; in men, erectile difficulty, the use of
erection assistance, ED based on SHIM scores, and history of prostate cancer treatment were added to the multivariate models. Only significant variables,
and coffee/tea use regardless of significance, were included in the final backwards elimination model. In women, being sexually active increased as the
ASFQ score increased (p < 0.0001), and alcohol was also positively associated (p = 0.0388) with sexual activity. In men, urinary
incontinence and ED based on SHIM scores were negative predictors of sexual activity (p = 0.0031 and p < 0.0001, respectively). Other
variables that were tested had no effect on sexual activity (Table 3).
Multivariable Analysis of Factors’ Impact on Sexual Activity
The current study represents factors associated with sexual activity in healthy, community-
dwelling older adults, as most (87%) respondents were in good to excellent health. Although the ability to compare findings across studies is limited by
varying definitions of sexual activity (Addis et al., 2006; Diokno
et al., 1990; Lindau et al., 2007), the proportions of sexually active men and women were
similar overall. MESA investigators reported that 66.6% of men and 31.7% of women 60 and older (73.8% and 55.8% of married men and women, respectively)
were sexually active (Diokno et al., 1990). Similarly, 68.2% of men were sexually active in the current
study; however, a higher proportion of women (62.8%) were sexually active. In another study that included slightly younger men and women (ages 40 to 80),
79.4% of men and 69.3% of women had engaged in sexual intercourse within the past 12 months (Laumann et al.,
2009). The current study, as well as others, noted a decline in sexual activity with age (Lindau et al.,
The results of the current study are in accordance with previous findings that sexually active older adults reported better overall
health (Lindau & Gavrilova, 2010) and mobility and are more likely to be married (Bach et al., 2013). However, in contrast to other studies (Barber et
al., 2002), urinary incontinence did not seem to affect sexual activity in women. The explanation for this finding is unclear, but it may be due
to the small sample and few incontinent participants overall. However, in men, incontinence was a significant negative predictor of sexual activity, which
is not surprising because urinary incontinence is also associated with ED (Coyne et al., 2011; Diokno et al., 1990). Because of the associations between overactive bladder, urinary incontinence, aging,
and sexual difficulties (Coyne et al., 2011), urology specialists should be particularly aware of the
need to assess for sexual problems.
The authors of the current article hypothesized that caffeine may be responsible for the previously reported
association between coffee use and sexual activity (Diokno et al., 1990); however, coffee and/or tea
consumption in the current study did not seem to have any effect. Other forms of caffeine, as well as coffee brand, type, amount, and caffeine
concentration, were not considered in either study but may have contributed to the discrepancy in findings. Sexually active women (but not men) were more
likely to report alcohol use. Other studies have also noted a link between moderate alcohol use and sexual activity in women (Addis et al., 2006). Although human sexuality is multifactorial and complex, alcohol consumption may lower
inhibitions and increase desire in women more than men.
Overall satisfaction with one’s sexual life may not necessarily be related to being sexually
active, as some study participants who were not sexually active still reported satisfaction. This finding suggests that the importance of maintaining one’s
sexual life is individualized and probably dependent on attitudes (Waite, Laumann, Das, & Schumm, 2009
), as well as partner availability (Bach et al., 2013). Lindau and Gavrilova (2010) reported that married men and women have more frequent partnered sexual activity than formerly
married or single individuals, especially at older ages; they noted that social and cultural norms may limit intimate sexual activity to individuals in
committed relationships. Although it is beyond the scope of the current article to examine factors associated with sexual satisfaction, higher levels of
satisfaction were reported in sexually active adults, indicating that sexual expression continues to be important as one ages.
Strengths of the current study include incorporating the SHIM and ASFQ into the survey and allowing participants
to self-define sexual activity independent of whether they were engaging in sexual intercourse. This expanded definition acknowledges other forms of
sexual expression, such as touching, hugging, and kissing (Ginsberg, Pomerantz, & Kramer-Feeley, 2005
), which may be used frequently, especially when individuals are adapting to physical or other impairments.
Limitations include a lower-than-
expected response rate and a lack of statistical power, which limited the authors’ ability to identify associations between sexual activity and
coffee/caffeine use. The authors had used an anonymous survey to protect participants’ privacy; however, some nonrespondents called the study telephone
number provided to participants for questions, but the number was used to object to the sensitive nature of study questions.
Future studies would
benefit from a more diverse population sampling to improve generalizability of results, the inclusion of validated quality of life and geriatric sexuality
questionnaires, and examinations of sexual health in lesbian, gay, bisexual, and transgender older adults.
The current study’s results support previous findings that urinary incontinence, poor health, and poor mobility are factors that
negatively impact sexual health. Nurses working with community-dwelling older adults or older adults residing in nursing homes should be aware of these
associations to provide comprehensive care. Older adults have been found to lack accurate and current information about sexuality (Rheaume & Mitty, 2008), and nurses are well suited to bridge this knowledge gap. Because health care
providers are often hesitant to discuss sexual health in older adults, significantly impacting the health of this population (Price, 2009), nurses and other providers should receive formal training regarding geriatric sexual health
needs so they have the adequate knowledge and skills to support older adults. Armed with the proper information and attitudes, nurses can promote sexual
health through education and counseling, particularly after major health events or in the setting of chronic illness (Steinke, 2013).
Maintaining sexual health will likely increase in importance as
more individuals live longer and in better health. However, much must still be learned about the impact of behaviors, habits, and illness on sexuality
among older adults. Ongoing study raises awareness that sexuality is important to the human experience, regardless of age, and can improve nurses’ and
other health care providers’ ability to communicate and help older adults address unmet needs.
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