AGE-RELATED CHANGES IN SEXUAL FUNCTIONING

Most of the epidemiological data suggest that there is a decrease in sexual interest and sexual behavior as one ages. It is often argued that this decline is due to biological changes in sexual response capacity. Age-related biological changes in capacity are difficult to determine because changes in sexual functioning are confounded by the effects of chronic diseases, medication, and cultural expectations. More-over, Winn and Newton (1982) have documen-ted examples of cultural influences on sexual response capacity. They studied data of the Human Relations Area Files of about 106 preindustrial and traditional societies all over the world. For 28 cultures, data on sexual activities in males were available. In 70% of these societies, older men had little or no reduction in sexual behavior until the age of 75.

Twenty-six cultures provided data about female sexuality, and 84% of these data reported continued sexual interest and activity in old females which often included having intercourse with younger men. This study gives some evidence that biological changes do not neces-sarily lead to a reduction in sexual interest and sexual behavior. Facts about physiological changes will be briefly reviewed in the following.

Detailed information is provided by McCona-ghy (1993), Morley (1991), Sarrel (1990), Schiavi (1990), and Schiavi and Segraves (1995).

7.04.3.1 Physiological Changes

7.04.3.1.1 Physiological changes in females Menopause is associated with marked hor-monal changes, namely, a decrease in estrogen production by the ovaries. There is an ongoing controversy about how the hormonal changes affect female sexuality (for a methodological review and meta-analysis see Myers, 1995). It was thought that decline in sexual activity was related directly to decline in sexual hormones, but estrogen and progesterone levels did not predict women's sexual functioning in the laboratory (Roughan, Kaiser, & Morley,

1993). Estrogen deficiency is responsible, how-ever, for decreased elasticity of the vaginal walls, atrophy of vaginal epithelium, diminished vaginal lubrication, and increased fragility of the vaginal skin (Goldstein & Teng, 1991;

Leiblum, 1990; Masters & Johnson, 1966, 1981;

Morley, 1991; Morley & Kaiser, 1989; Roughan et al., 1993; Schiavi & Segraves, 1995; Wise, 1989). These changes are probably responsible for coital pain, which is more often reported by postmenopausal women. Estrogen replacement therapy is very successful in treating these vaginal changes.

Although Masters and Johnson (1966, 1981) studied only 11 women aged over 60, their description of physiological changes in healthy women proved to be accurate and their data have been supported by findings from self-report surveys (Bachman & Leiblum, 1991;

Dennerstein, Smith, Morse, & Burger, 1994;

Hagstad, 1988; McCoy & Davidson, 1985;

Morley, 1991). Physiological changes in female sexuality include decreased congestion of the labia minora, decreased separation of the labia majora, decreased vaginal lubrication, de-creased orgasmic platform contraction, and occasional painful spastic contractions of the uterus. Furthermore, the breasts become less vasocongested and nipple erection is less likely to occur. Masters and Johnson (1981) reported that aging women require more time in precoital stimulation until lubrication develops suffi-ciently. Orgasmic duration and intensity may be reduced but the capacity for multiple orgasms remains.

There is some ongoing controversy as to whether women suffer sexual dysfunction following hysterectomy. Bernhard (1986) ana-lyzed 18 studies and detected numerous meth-odological and measurement problems. Eicher (1994a, 1994b) reviewed research outcomes and concluded that older studies reported negative, and newer studies positive, consequences for female sexuality. He argued that this change is due to better information, sexual behavior advice, and historical changes in attitudes towards sexuality. Results from a recent long-itudinal study with 104 women revealed that half of the women reported improvement after surgery and 21% reported poorer sexual functioning. Preoperative sexual activity was the best predictor of postoperative sexuality (HelstroÈm, Lundberg, SoÈrbom, & BaÈckstroÈm, 1993).

Dennerstein et al. (1994) reported a study with 2001 randomly selected Australian women aged between 45 and 55 years. The natural menopause transition was clearly associated with declining sexual interest, decreased like-lihood of intercourse, and increased likelike-lihood Sexuality

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of unusual pain during intercourse. HaÈllstroÈm and Samuelsson (1990) reported data from 497 subjects with a male partner who were viewed twice within seven years. At first inter-views, subjects were aged 38, 46, 50, or 54. Of the total sample, 27% reported a decrease in sexual desire and 10% experienced an increase in desire. Age-group differences were marginal.

Antonovsky et al. (1990) conducted retrospec-tive interviews with 121 women and 177 men between the ages of 65 and 85. The women reported a marked decrease in sexual desire and sexual satisfaction in comparison to their twen-ties, thirtwen-ties, and fifties. McCoy and Davidson (1985) conducted a longitudinal study and reported a significant decrease in coital fre-quency and sexual thoughts in the postmeno-pausal compared to the premenopostmeno-pausal period.

The decline in coital frequency was related to testosterone rather than to estrogen levels.

Sarrel (1982) described sex problems after menopause in 50 couples (e.g., loss of orgasmic response in female partner, erectile difficulties in male partner) who participated in a sex counsel-ing program. Dyspareunia in women was often followed by erectile difficulties in men.

In contradiction to the reviewed data, which support a decline hypothesis, Starr (1985) claimed that ªthe Starr±Weiner data indicate that women over 60 are more orgasmic than when they were youngerº and that ªmost investigators report that sexual response re-mains the same or improves after menopauseº (Starr, 1985, p. 102). Epidemiological data from a representative cross-sectional study clearly suggested that the number of women who never experience orgasm remained fairly stable until the age of 70 (Laumann et al., 1994). These data do not answer the question, however, whether orgasmic women increase their capacity to orgasm after menopause.

7.04.3.1.2 Physiological changes in males Men do not undergo a clearly marked, obvious change such as females experience with menopause. Nevertheless, there is a remarkable change in hormone production as well; namely, a decrease in testosterone and bioavailable testosterone in the majority of males (Morley &

Kaiser, 1989). Decrease in testosterone produc-tion has led to the hypothesis that androgen deficiency contributes to the decline in sexual desire and activity in older men (Schiavi, 1990).

Remarkably few studies, however, assessed the role of gonadal hormones on age-related changes.

Schiavi and colleagues investigated 77 healthy, married men aged 45±74 and their partners. The sample was drawn via media

announcements. Couples underwent an exten-sive interview together as well as separately.

Data gathering included psychosexual, psychia-tric, and marital information as well as a battery of psychological tests. The male subjects were additionally studied in a sleep laboratory for four nights. Electroencephalogram, eye move-ments, muscle tone, and penile tumescence were monitored. Data revealed that age was nega-tively correlated with bioavailable testosterone.

Bioavailable testosterone showed significant associations with sexual desire, arousal, and activity measures. Furthermore, results showed age-related changes in nocturnal penile tumes-cence. Frequency, duration, and rigidity of this reaction decreased with increasing age. Finally, age was significantly negatively correlated with sexual desire, sexual arousal, and sexual activity, but there were no age differences in degree of enjoyment of marital sexuality.

Increased age was also correlated with erectile difficulties (erectile rigidity, loss of erection during sex) and retarded ejaculation (Schiavi, 1990; Schiavi, Mandeli, & Schreiner-Engel, 1994; Schiavi, Mandeli, Schreiner-Engel, &

Chambers, 1991; Schiavi, Schreiner-Engel, White, & Mandeli, 1991).

Masters and Johnson (1981) described four variations in basic sexual physiology in males who were past their mid-fifties. First, it takes longer to achieve full penile engorgement and requires more direct stimulation. Second, there is a reduction of expulsive pressure. Third, there is a reduction of the volume of seminal fluid expelled. Fourth, there is a reduction or loss of ejaculatory demand. Weiss and Mellinger (1990) stated that there are only one or two expulsive contractions of the urethra instead of four major contractions in younger men.

Seminal fluid is expelled with less force, which diminishes the sensation of passage through the urethra. There is, rather, a seepage of semen which reduces the intense sensation of ejacula-tory inevitability. After ejaculation, the refrac-tory period increases with age. Many men cannot have another erection for 12±24 hours.

Further physiological changes include less nipple erection; less, or absence of, flushing of neck, trunk, shoulders, thighs, and forearms;

scrotal integument becomes thinner and in-elastic; rapid detumescence after orgasm (Weiss

& Mellinger, 1990).

7.04.3.2 Psychological Aspects

Modern developmental psychology empha-sizes that development is not limited to childhood or youth but continues over the life course. This life-span perspective views

devel-opment as a product of an interplay between biological, cultural, and psychological influ-ences, that is, individuals interact with their environment continuously over the life course (Baltes, 1987; Baltes, Reese, & Lipsitt, 1980).

Cultural influences change considerably with time. This fact can be illustrated by a closer look at elderly subjects who were investigated, at age 70 in 1980. These subjects were born in 1910.

Their parents grew up in the Victorian century.

This means that these subjects were exposed to very strict societal norms regarding sexuality during their childhood and adolescence. Mas-turbation was forbidden and considered to be extremely harmful. Sexual feelings for decent women were unthinkable. Freud's theories and discoveries, especially his description of sexual feelings in children, were regarded as tremen-dously scandalous in Vienna at the beginning of the century (Freud, 1964). Despite short periods with less restricted sexual norms (e.g., in Berlin during the 1920s), sexuality remained a ta-booed, guilt- and shame-laden topic for many years. Considerable changes began with the pioneering work of Kinsey and his colleagues (Institute for Sex Research, 1953; Kinsey et al., 1948) who provided the first published survey of sexual behavior. Masters and Johnson (1966) followed with serious information about ªhu-man sexual response.º Their work was a break-through for the acknowledgment of female sexuality. At the same time the development of the contraceptive pill, the ideas of the hippie movement, and later feminism, contributed to the liberation of sexuality. During the 1980s, the threat of AIDS reduced sexual freedom. The above-mentioned subjects who were 70 years old in 1980 experienced all these influences, but the development of their sexual identity was strongly influenced by Victorian moral stan-dards. The fading of sexuality over ontogenetic time might be, therefore, a product of socializa-tion rather than of biology (Traupmann, 1984).

In addition, cultural influences are very important for age-graded behavior expectations and societal values in general. Modern Western societies are dominated by youth orientation, and sexuality is linked to it. Firm and slim bodies, smooth skin, health, energy, career orientation, money, and luxury are highly valued. All these characteristics are directly or indirectly related to youth, sexual attractive-ness, and potency. Elderly people have the difficult task of coping with these societal norms which threaten their self-esteem.

Elderly homosexuals suffer from multiple myths and stereotypes. These stereotypes in-clude that aging gays are oversexed, frustrated, unable to have a lasting relationship, and have an extreme youth orientation (Pope & Schulz,

1990). McDougall (1993) described these myths, and stressed cohort differences between young-er and oldyoung-er gays. Eldyoung-erly gays are used to hiding their sexual preferences, in contrast to younger ones who have benefited more from the gay liberation movement in the 1970s. Cruik-shank (1990) reviewed gerontological studies about aging lesbians and gays, and concluded that there were more positive outcomes than expected. Friend (1990) presented a ªtheory of successful agingº (p. 99) for lesbian and gay individuals. He theorized that the tough lifelong reality with numerous experiences of discrimi-nation leads to the development of a strong ego in gays. They are thus better prepared to cope with the demands and humiliating experiences of aging than the heterosexual elderly.

For women, cultural pressure is particularly damaging because esthetic and erotic feelings in Western societies lead to old women being considered as repulsive (Sontag, 1972). Whereas wrinkles and gray hair are an interesting and attractive sign of experience in men, they are a symbol of decaying beauty and femininity in women. A marriage of an older man and a young woman is a sign of vigor and vitality in the man, but when an older woman marries a young man, it is generally disapproved or even judged as pathological. An illustration of this humiliating experience for women is provided by Thomas Mann. Being himself in his late seventies, he wrote a story about a 50-year-old woman who fell in love with a young man. With his deep psychological understanding of human conflicts he described desire, restriction, and a ªbetrayal by natureº of this woman (Mann, 1953).

Men also have to face cultural pressures.

Male identity and masculinity is directly linked to sexual performance demands. Books, stories, movies, and television shows project a ªfantasy model of sex: It's two feet long, hard as steel, and can go all nightº (Zilbergeld, 1992, p. 30).

The penis is expected to function automatically whenever its owner wishes to use it, regardless of any other conditions. Older men who feel a normal need for more direct stimulation or experience erectile weaknesses can be threa-tened to the core of their identity. As a 51-year-old man put it: ªYou want to know how I feel, I'll tell you. I feel like an absolute nothing. I know I can satisfy her in other ways and I do, but that's not the point. I feel like shit, like the center has been taken out of meº (Zilbergeld, 1992, p. 36). Unfortunately, because of this culturally shared fantasy model of male sexu-ality, many women interpret occasional lack of erection as if they were rejected, not desired, not loved, or not attractive enough. Women have difficulties understanding the intense threat that Sexuality

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erectile problems pose for men because they have no parallel experience. The female gender identity will not be questioned by any sexual dysfunction because it is not linked to sexual performance. In addition, women can almost always perform sexually: they can have inter-course without being aroused and can fake enjoyment, but there is no way to fake an erection.

These cultural influences, shared and gender-specific ones, are of considerable importance for psychosocial development and well-being in the elderly (Rosenmayr, 1995). Aging indivi-duals as well as aging couples have to cope with various developmental tasks. Robert Peck (1956) described three phases of development in late adulthood: ego differentiation versus work-role preoccupation, body transcendence versus body preoccupation, and ego transcen-dence versus ego preoccupation. The first phase refers to coping with retirement. The crucial question is whether a person can derive self-esteem from activities other than work.

The second phase means coping with physical decline and health problems. The last stage is very similar to Erikson's (1950) description of ego integrity vs. ego despair as the outcomes of the final developmental task in old age.

Acceptance of one's unique life with unchange-able failures and the realization of death are the most important challenges of this stage.

These difficult tasks represent a threat to normal narcissism and can have pathological consequences (Eckert, 1984; Liptzin, 1984).

Kernberg (1977) described the difference as follows:

It is part of normal narcissism to love oneself, to be satisfied with one's own appearance, and to wish to be accepted, liked, and loved for what one is.

The problem begins when a highly ideal, beautiful and triumphant image of the self linked to child-hood or youth becomes an indispensable precon-dition for self-acceptance and for trusting that one will be accepted by others: this usually reflects a deep devaluation or depreciation of one's self, a sense of loathing and distrust for one's present appearance and value, which can only be compen-sated for by the eternal looks of triumphant adolescence. (pp. 27±28)

Coping with the narcissistic wounds of aging is a major task for every individual. Fortu-nately, empirical data indicate that most elderly people manage well and retain positive self-esteem and life satisfaction (Bengtson, Reedy, &

Gordon, 1985; Costa et al., 1987; Staudinger, Freund, Linden, & Maas, 1996).

Intimacy and intimate relationships seem to be especially important for coping with the demands of aging (Weiss, 1983, see also

Chapter 3, this volume). Intrapsychic changes and role transitions additionally challenge the aging couple. Two examples are marital life after children have left the household, and the retirement of one or both partners. As one woman commented on her stress with the retirement of her husband: ªI married my husband for better or for worse, but not for lunchº (Leiblum & Segraves, 1989, p. 377).

Life-span development of gender identity and the concept of androgynization with age has important implications for the individual as well as for the interindividual dynamic of couples and their sexuality (Livson, 1983). Jung (1933) reasoned that role demands in early adulthood require development of selective domains and that older people show greater awareness of aspects of their self which were suppressed earlier. ªThe man discovers his tender feelings and the woman her sharpness of mindº (p.108).

Colarusso and Nemiroff (1981) theorized that oedipal issues might reawaken because of illness and death of parents. Therefore, internal representations of parents may change and alter the adult's self-concept. This change in personality may also effect sexual feelings insofar that long-standing relationships are higher valued than short-term sexual gratifica-tion (Nadelson, 1984).

Finally, aging couples have to face possible dependency of one partner due to chronic illness, and separation through death. Coping with increasing losses of significant others is one of the most difficult tasks for elderly people.

Death of the partner means for many tradi-tionally oriented women, besides many other losses, the end of any sexual activity (Malatesta et al., 1988).

7.04.3.3 Health-related Changes

One major problem in examining age-related changes is that the distinction between age-related and health-age-related changes is almost impossible. Chronic illnesses increase markedly with age and most diseases have a direct or indirect effect on sexual functioning. Thus, it is not aging per se, but comorbid illness that may cause an increase in sexual dysfunction (Schover, 1989, 1992; Spence, 1992). Some authors claim, however, that health aspects tend to be overestimated with regard to sexuality (Fooken, 1994). Common chronic diseases will be briefly reviewed in this section.

An excellent overview about geriatric sexuality and chronic diseases is provided by Mooradian (1991). Additional information is given by Burgener and Logan (1989), Gupta (1990), Kaiser (1991), Liptzin (1984), Majerovitz and

Revenson (1994), and SjoÈgren, Damber, and Liliequist (1983).

7.04.3.3.1 Diabetes mellitus

The prevalence of diabetes for Caucasians aged over 65 in the USA is 7% for men and 9%

for women. For the black population aged over 65, it is 12% for men and 15% for women (Zemel, 1988). Diabetes is an important cause of sexual dysfunction. Orgasmic impairments are experienced by 18%±35% of women. Impo-tence, retrograde ejaculation, premature ejacu-lation, and oligospermia are reported for men.

At 65 years of age, up to 75% of diabetic men are impotent (Mooradian, 1991; Newman &

Bertelson, 1986; Zemel, 1988).

7.04.3.3.2 Cardiovascular disease

Prevalence of this disease increases with age, and the disease causes over 50% of deaths in individuals aged over 64 (Wise, 1989). Both organic and psychological factors affect the sexuality of individuals suffering from cardio-vascular disease. Orgasmic difficulties in wo-men as well as erectile dysfunction and premature ejaculation in men are reported (Wise, Epstein, & Ross, 1992). Following coronary bypass surgery, the sexual desire of women appears to decline, while an increase in

Prevalence of this disease increases with age, and the disease causes over 50% of deaths in individuals aged over 64 (Wise, 1989). Both organic and psychological factors affect the sexuality of individuals suffering from cardio-vascular disease. Orgasmic difficulties in wo-men as well as erectile dysfunction and premature ejaculation in men are reported (Wise, Epstein, & Ross, 1992). Following coronary bypass surgery, the sexual desire of women appears to decline, while an increase in