Sex Matters: Keeping Sex Alive for Life
SEX IN OLD & NEW WAYS
by Walter M. Bortz, M.D.
If you’re going to live a long time, it makes good sense to get a handle on the basic drives that make life happen. Eating, breathing, and moving come to mind immediately. And sex?
High up on the list of reasons that people use to claim they don’t want to live to be 100 is diminished sex life. They imagine themselves as frail shells of their former selves who would not only be physically incapable of a sex life, but probably not interested, either.
Yes, your sex life will change, but thank goodness! It certainly changed between adolescence and age 40, didn’t it? The key is to enjoy what you can do at every age.
TIP: Old people can. Old people do. In fact, several scientific reports
indicate that if you really are planning to be 100, having a good sex life
is a good place to start.
In this article I build the premise that life-long sexual activity is not only possible but also desirable. I review the recent science behind this perspective and document the positive aspects of late-life sexuality. In so doing, I don’t neglect or obscure the large amount of negative imagery associated with sex and aging, but I do hope to place it in context and to provide action steps you can take to prevent the sad and usually inaccurate predictions. The widespread myth exists that sex belongs exclusively to the younger generations. This idea has been thoroughly and thankfully demolished by numerous surveys. Not only do old people maintain a robust and lively interest in sex, but, more importantly, they follow their urges.
In the past, when questions would arise from patients and listeners in lecture audiences about sexual matters, I would stumble badly. In an effort to get on the stick and repair this ignorance, I read and studied everything I could, but still felt inadequate. So, I decided to put on a public forum on the topic. Several colleagues and I advertised a three-evening series about sex and aging to be held at our local senior center.
As the first evening approached I wondered "What if no one shows up?" I needn't have worried because the place was packed, and, interestingly, most of the audience was male. This contrasts most lectures on aging topics where the attendees are largely female. The average age of our audience of nearly 200 was 68, and they were acutely attentive throughout. The majority of the attendees were married or had a sexual partner. Our expert panel went over topics ranging from anatomy and function to disease and drugs — everything was on display. Questions and concerns bubbled up. At the end of the series, we handed out a questionnaire about attitudes and performance. Completing the questionnaire was voluntary and anonymous, but most everyone sent it back. The responses revealed two major findings. First, the group was very interested in sex and was busily pursuing this interest. Second, the group’s sexual interest and performance were both burdened by numerous problems — some of which were predictable and others of which were totally unexpected in nature.
Ninety-two percent of our lecture group reported that ideally they would wish to have sex once per week. This figure was similar for men and women, and for those less and more than 70 years of age. Interestingly, this preferred frequency conformed to that of the attendees’ reported practices 10 years earlier, but was notably less than currently practiced. In other words, both the men and women wished for more frequent sexual encounters than they were experiencing.
The male respondents placed a higher value upon intercourse as their preferred form of sexual activity, whereas the females rated "loving and caring" most highly. This observation is reminiscent of an aging/sex study at Duke University several years ago in which male respondents seemed to place more emphasis on the quantity of their sexual encounters, while the females indicated a more persistent interest in the quality of the encounters.
Despite the generally lusty attitude and activities of our evening group, we did note a clear fall in frequency of sexual expression with age. Sixty percent of the group indicated a decrease in sexual performances in the last 10 years, 32 percent indicated no change, and 8 percent indicated an increase. These statistics are similar from those of a larger study conducted 15 years ago. In this report performed by the public interest group Consumers' Union, 73, 63, and 50 percent of women in their fifties, sixties, and seventies, respectively, reported having intercourse at least once per week. Correspondingly, the percentages were 90, 73, and 58 for the same decades in men. Further, 50 percent of the men over 80 in this group recorded sexual activity at least once per week.
The critic will ask, "How do you know these figures are not all exaggerations?" The answer is, “You can't know for sure, but checks within the questionnaires reflect an internal consistency, and thereby provide confidence in the meaning of the results.” What is more certain about the figures, however, is that they are very likely to change as societal attitudes change. An 80-year-old of today is a very different person, sexually and in other ways, than the 80-year-old of 50 years from now. I can only predict that the sexual numbers cited in the previous paragraph will increase.
Several experts have commented on the relative stability of sexuality over the life span, which means that if you and your mate had a vigorous approach to sex in your 20s, you’ll likely carry on that trend until late in life. The old saying of "use it or lose it" is affirmed again. This constancy does not, however, account for the substantial numbers of older men and women who report that their sexual profiles in late life are better than they have been. Psychiatrist Eric Pfeiffer wrote that 20 percent of older men feel their sexual lives are better than they were at younger ages.
Sexuality sits wonderfully at the intersection of the biological, psychological, and sociological domains of life. All three are active participants in a wholesome sexual life. Although it is unlikely that biologic change with age would likely confer any advantage to older persons (other than the possible relief from anxiety about possible pregnancy that accompanies a menopause), it is very possible that a great variety of psychological and social adjustments occur with aging that could predictably enhance sexuality.
From a strictly biologic and reproductive point of view, sex is best left to the young. This conception is based on the indisputable fact that age provokes gene change that has major implications for family planning. Whereas only 1 in 526 20-year-old women show chromosomal defects in their ovaries, this frequency rises to 1 in 7 for 49-year-old women. Determination of male sperm chromosomal pattern is less sternly age affected.
These are interesting and important facts, but they should not obscure the fact that, for humans, reproduction is only a very secondary component of sexual activity. For most of us, sex represents the ultimate in social bonding. It generates long-term commitments, respect, and devotion. It encourages mutual spiritual growth. All of the psychosocial roles that sex plays in us humans do not diminish, in fact should enlarge, as the decades pass.
The flush and rush of early chemical infatuation is on most dramatic display in young lovers, but old lovers can twinkle too. On the other hand, the fine polish that only late-life companionship offers is a deeper and more enduring gift.
So, sure, age matters with sexuality. Along with the well-documented decrements of sexual performance, however, come opportunities for sustaining a long and caring relationship into the tenth decade and beyond.
The first “sex practice in aging” survey I did, mentioned earlier in this article, showed clearly that our older subjects both thought about and acted upon sex more than was expected. The second strong finding was that problems do exist. Both men and women have problems. Eighty-five percent of the men under 70 (79 percent of those over 70) and 63 percent of the women under 70 (44 percent of the women over 70) reported that they were either somewhat or very troubled by some aspects of their sex lives. What were the problems? For men, the difficulty expressed was nearly exclusively confined to impotency. For the women, the problems had more to do with social rather than biologic issues.
To explore in more depth the troubled male, I initiated another large survey, this time exclusively with men. Through lectures and a number of retired men's luncheon clubs a sample of 1,202 men was obtained. The average age of the respondents was 73.8, with 18 percent over the age of 80. A 63-item questionnaire asked assorted questions dealing with present and past sexual attitudes and practices.
Once again, a falloff in average sexual activity was noted. The 55 to 59 year age group reported a median value of 3.6 times per month for sexual intercourse, while the 85 to 94 year age group reported only 1.3 times per month. Great variance existed within these groups. Five percent of the 228 men over 80 years of age reported having intercourse two or more times per week, and an additional 12 percent had intercourse at least once per week. There was, therefore, a subset of the older men to whom the declines did not seem to apply.
We asked why. Three answers emerged. First, these lusty 80-year-olds had good physical health, second they took few if any medicines, and third they had a willing and loving partner. We termed this group our "exemplars." They represented the reality that for a substantial number of older men impotency and diminished sex lives are not in fact inevitable.
I published these results in the May 1999 issue of the Journal of Gerontology. The conclusion stated, "These findings negate a portion of the starkly negative imagery of sexual expression in aging males." It is therefore heartening to be able to state boldly that there is hope, that impotence is not the sure fate of us guys as we age.
The fact remains however that the great majority of older men suffer from some degree of impotence.
The handful of scientific projects designed to look into the topic of sex and aging are in agreement on several findings. First, older people are more sexually active than is generally appreciated. In one report, college students estimated that their parents made love three times per month. The actual frequency was seven times. One-quarter of the students guessed that their parents never made love.
Second, consistency of lifestyle predicts late-life sexuality. If sex is an important component of earlier life quality, it is more likely to be sustained into late life. Twenty percent of older men feel that their sex lives are better than earlier in life. Women too report lessened tensions, inhibitions, and better communication about sex in their upper decades.
Third, problems do exist. Identifying that you may have a problem is key to ensuring a long and healthy sex life. For men the principal difficulties involve impotence. For women it involves lack of opportunity. Illness, death, and medication use make men less able and available consorts for women.
Male sexuality and aging
As we men age, we age in many ways. Among the most important is our sexuality. Both in terms of desire (libido) and performance, we simply aren't the same person as 10 or 50 years ago. Some aspects, such as having more leisure time and lowered performance pressures, are conducive to improved sexuality. Other features, biologic ones, are negative. The most common of these is impotence.
Millions of older men acknowledge various degrees of difficulty in achieving or maintaining an erection. Only recently have scientists begun to understand the biology of having an erection. Doctors have always known that an erection results when the penis fills with blood, but the specific mechanism was totally unknown. Now we know.
The little molecule that dilates blood vessels wherever they are in the body is nitric oxide. It is the active ingredient in nitroglycerine, which is a widely used little pill for the treatment of heart pain (angina). When the heart arteries are constricted, the heart becomes starved for blood and a crushing chest pain results. Put a nitro pill under the tongue and “ah, relief” as the nitric oxide relaxes the arteries and allows the blood to flow again. Frequently headaches accompany the use of the pill because it is not smart enough only to dilate the heart arteries and dilates the ones in the head too. Because scientists know how nitric oxide works on arteries all over the body, concluding that nitric oxide initiates an erection was not much of a leap of logic.
Initial efforts to apply a salve or cream of nitric oxide to the penis to cause an erection failed because the cream’s time of action was too short. Consequently, compounds that generate nitric oxide when ingested (first alprostadil and, more recently, Viagra) entered the market. Viagra’s introduction represented the single most explosive new drug in history. (I wish I had bought stock.) The Pfizer Company discovered Viagra’s effect as an accident. The drug was initially promoted as a blood pressure lowering medication, but it didn’t work very well. As a result, Pfizer decided to recall all the samples that had been distributed as part of the mass testing of any new drug. They were surprised when the men refused to send back the samples. Hence, Pfizer had a big winner, unexpectedly. Viagra has been a very successful drug for men with erectile dysfunction (to use Bob Dole’s term). Rarely, there have been fatalities associated with its use, although some have occurred particularly with men who are taking nitroglycerine simultaneously (not a good idea). Always seek advice from your physician prior to taking any medication — never “try” other’s medications.
Impotence occurs because collagen deposits in the vascular channels of the penis and clogs them up. The answer to this problem is to get rid of the collagen by having an erection. Erections are good for erections. The principle of “use it or lose it” is again affirmed. There probably should be a RDA (recommended daily allotment) of erections for maintaining good erectile competence.
For men the ability to have an erection is much more than a biologic event. It is identifying. It is a life competence. It is an essential marker of the intactness of our ego. In addition to the previously mentioned new knowledge about the mechanical details that produce an erection, there has been extensive sober reflection on all the factors that bear on this capacity, including:
The prostate presents two problems to the older male. The first goes by the name of benign prostatic hypertrophy (BPH for short). This non-malignant enlargement causes a gradual swelling of the prostate so that it takes up too much of the volume of the urinary bladder or it may actually shut off the urethral urine flow. The common symptoms have to do with urinating — excessive, difficult, or nocturnal. Surgery is the current principal treatment of this non-life threatening but distressing condition. The other prostate worry is cancer. Magazine covers, TV specials, and ad campaigns all detail what seems to be an alarming increase in incidence of this condition. Some of the increased incidence, however, is due to the availability of the simple blood test, prostate specific antigen (PSA), which is very helpful in detection. This test should be on the required list of annual physical exams for men in the 65 to 80 year age group. Multiple treatment options are available, and require having a good, caring physician.
And what about women? The truth is, the scientific community knows even less about women than men. While the male problem is largely mechanical, the female issues are much more complex with biologic, psychologic, and social factors all interplaying. Betty Friedan’s book Fountain of Age includes an excellent chapter on intimacy issues of older women, which describes with much sensitivity the lack of conceptual framework from which advisories can be derived. If desire is low (libido), testosterone is of proven value for women as it is for men. Several preparations, including skin patch and a cream, can raise the sexual interest of older women. Hormone replacement with estrogen and progesterone is now widely advised for older women for a variety of reasons, not the least of which is the facilitating of good health of the female sexual tissues. Lack of estrogen commonly promotes atrophic vaginitis, which is often a stern disincentive for sexual activity.
The main event in the older woman's sexual life is her menopause. Once again, the cessation of menstrual periods has much more than biologic significance. It signals the end of reproductive capacity, which for many women is central to their life role. For many women this loss is profound, while for others it is a relief or liberation.
The loss of monthly production of estrogen has real biologic meaning. It is no accident that until menopause, women (unless they are smokers) are virtually immune to heart attacks. The menopause signals the end of their immunity. Estrogens have been implicated too in the protective effects against osteoporosis. Alzheimer’s disease is also nominated as a condition that may be ameliorated by hormone replacement therapy.
What, to me, was a very strong story supporting these estrogens in post-menopausal women for the three indications mentioned previously has been modified by several large epidemiologic surveys that were less than enthusiastic in their results. Therefore, in my opinion, we are in a "wait for more evidence" mode before endorsing widespread use of estrogens after the menopause.
The value of estrogen taken either orally or applied locally for thinned and sensitive genital tissues is beyond dispute. Analysis of female adequacy for satisfactory late-life sexual activity is far less studied or revealing than for the man. Clearly, tender tissues is easily remedied. Less easily solved, however, are the issues of lack of interest and lack of opportunity. "I don't really care about sex" is obviously not an attitude that leads to a promising sex life. When I hear this lament, I do not blithely and respectfully defer to it. To me, sexuality is a huge quality of life issue for women as well as for men, and anyone who shuts this out, with or without good reason, is a sorrow. When one of my patients says to me, "I don't feel like exercising," I don't accept that verdict, I try to change it. So, too, if disinterest in sex appears in a female patient, I try my clumsy best to address it. If I fail, however, I am quick to advise consultation with a sex therapist.
I acknowledge that this aggressive approach to the younger-older lady has some rationale, but I am troubled by the appropriateness of my urging to a 90-year-old who may have been widowed for 15 years. Accepting the reality of this situation, I nonetheless cling to my ideal that life is to be lived fully and robustly until its last ember dies, hopefully after your 100th birthday. And this fully robust life connotes some form of sexuality and intimacy, even when the odds are stacked against it.
The other negative older female sexuality issue is simply numerical. There aren't enough of us older guys to go around. The simple answer to this quandary is for the men to live longer so that the ratio is more equal. Yet, lacking a slick answer to this suggestion, we are stuck with a statistical imbalance. Fortunately, women, lacking men, appear to turn to other older women in the same predicament in which they find themselves for companionship and understanding. Women bond with other women much more comfortably than men bond with men. It bothers me a lot that when a wife dies, the husband's mortality is at great risk. On the other hand, when a husband dies, the widow seems not to be threatened by his absence.
I am struck by the term "social convoy." This term reflects the circle of intimate contacts most of us surround ourselves with as life winds its way. Our individual social convoy is a major survival tool. Those who lack it simply don't live as long. Women are notably more adept at constituting and maintaining their social convoy.
The majority of age/sexuality features listed under male issues in the previous section (boredom, depression, stress, fatigue, alcohol, health and medicine, and spousal incompatibility) also conspire to diminish the quality of an older woman's responsiveness. All of these issues apply to women, and they matter a great deal.
A sad but true observation is in order. We physicians are abominably bad in dealing with sexual issues with our older patients. We are embarrassed, ignorant, and threatened. We, as a profession, have a great deal of maturing to do to deal effectively with this important issue.
Keeping the Flame Alive
Instead of late-life sexuality representing a dying ember, soon to extinguish, it should be thought of as a lingering warmth that requires tending to ensure continued flame and sparks. This cannot happen casually. It takes planning and mutual commitment.
All those complications which crowd the quiet romantic moments — congested housing, medication use, arthritis, grandchildren — have solutions. Don't forget that earlier in this article (under “Now the bad news”), I wrote about the "sexual exemplars" whom we identified in our research study. Although our study group was exclusively older males, I am confident that the same qualifying attributes apply to older women as well.
In order to be a sexual exemplar as you age, first you need good health. This is largely under your personal control with your physician's assistance. Careful attention to medication use is critical. Important too is creating the time and space for intimacy. Here are some tips for connecting with your significant other:
Every older person can summon up from deeply stored memories images of a full moon over the water, or the last slow dance at the prom, or smooching in the back seat at a drive-in movie, or the smell of perfumed hair, or a corsage, or self-conscious love notes — the list goes on and on. But the point is: Are these memories necessarily confined to the awkward and often anxious teenage years, or can romance linger into the present? Love need not go stale with time, but, like a successful garden, it needs plenty of attention. If recalling those infatuated moments still can give goose bumps of pleasure, why not rekindle these embers? No one is ever too old to deny the delight of candlelight dinners, or an unexpected present, or a massage, or a sweet love song. Wedding anniversaries provide perfect opportunities for rededication and rediscovery of the sweet moments. Being healthy and happy together is the "right stuff." Romance makes the rest of the world glow brighter. It boosts common energies and enhances longevity.
Sex is a large part of quality of life at any age, young and old. Evidence even suggests that sex might extend your life. In 1997 an article appeared in the British Medical Journal entitled “Sex and Death, Are They Related?” It concerned a survey of 1,222 men aged 45 to 59 from Caerphilly, South Wales. After 10 years, 150 of the men had died. The sexually active group had half the mortality of the sexually inactive group.
As I hope for my eyes, ears, heart, legs to be fully functional until my terminal decline, so too do I hope that my sexual flames still burns brightly until the end. Aging brings advantages to sexuality and sexuality gives polish to the image of aging. It maintains bonding. It is virtual communication. It is affirming. It is smarter, less urgent, and more honest. Sustaining sexuality, as sustaining physical exercise, should be a common life goal. The more informed we become about aspects of our basic nature, the more capable we will become of finishing life as we started — with bright eyes and a tender heart.
One of the persistent and troubling aspects of late-life sexuality is the numerical disparity of older women and men. This is due to the well-documented spread in life expectancies between the two sexes.
Why do women outlive men? My mother was a widow for 22 years after my father died. Although the length of her widowhood exceeded the usual duration of seven or eight years, such a prolonged loneliness is not rare. What is the explanation for women's longevity advantage? There is no clear answer to this simple question, but there are many conjectures. It seems that Mother Nature places a higher value on the lives of her female descendents than on those of her sons. This advantage is widely seen throughout all creatures.
I read an interesting speculation that noted that in those species in which the male is an active partner in child rearing, the gender/life span disparity is less than in those more common circumstances in which the male fulfills his biologic role by sperm donation, and is never heard from again. Nurturance and longevity sound like they should go together.
Others speculate that the reason men die too soon is our bad health habits. Until recently, smoking was mostly a male habit. Unfortunately, however, its embrace by women has diminished their immunity to smoking-induced illnesses — and the death certificates give grim evidence of this fact.
My own best guess as to why women outlive us guys has to do with their coping abilities. Women bend, men break. Women are supple, men are rigid. Women tend to their health better than men do. They use their doctors and healthcare system better than men do.
Interestingly, speculation exists that as men age they become more feminine in perspective and in biology. As the male testosterone levels fall with age, men become less irascible, less confrontational, and nicer (or so the theory goes). It would certainly make a neater and more balanced world if men's longevity equaled women's.
Implicit in any discussion of late-life sexuality is a concern that the exertion encountered during sex may be the tipping point to an otherwise frail person. What would people think if grandpa died while...?! To give you a reference point, intercourse is roughly equivalent in terms of exercise intensity to climbing a flight of stairs. The risk of heart attacks in a low-risk person is about 1 per 1 million hours. Sexual activity doubles this to 2 per 1 million hours.
This is an extremely small risk. Further, you can totally offset the risk by being physically fit — another credential to add to the benefit list of physical exercise. I surveyed sexual habits of the members of the physically active Fifty Plus Fitness Association. This group is known for having a disability and mortality rate that is only 30 percent of the national average. The male and female members of our extremely physically active group reported above average sexual interest and activity. Which causes which? Do the members live longer because they are sexually active, or does their physical activity confer late-life sexual competency?
This article and the entire topic of late-life sexuality are extremely important to me personally. As a healthy 70-year-old male, I thank my stars that I live in the era of sexual illumination. No longer are these topics hidden from public and even private review. Sex is labeled, properly, as a central quality of life issue for people of all ages. It pervades every corner of our lives. It can anguish, but it can exalt. I prefer the latter, and the more we know the less the anguish will be.
Our first 1996 sex and aging study reporting the results of a small seminar asked first about the amount of sexuality older people experience, second how we feel about it, and third and most importantly can anything be done to improve it? The results of our and other information leads to three responses. First, older people maintain a largely unrecognized vigorous interest in and pursuit of sexual pleasures until late in life. Second, those who fail, for many reasons, feel their sexual experience to be less than they would wish for and are upset by it. Third, their unhappiness is approachable, and, in many ways, improvable.
Being healthy, sexually, and in all other ways is under your personal control. Responding to this reality makes sense.