Over the past decade, there has been a surge of interest in studying the sex lives of older people. There are a number of factors contributing to this interest, not the least of which is the global and accelerating trend of population aging. Declining birth rates, combined with longer life expectancies, have contributed to a growing proportion of the population deemed 'old', and to an increasing number of years that people will live in old age.

These demographic shifts have raised concerns about potential strains on health care resources, and sexuality, through its presumed linkage with 'healthy' or 'successful' aging, has been incorporated into predictive models and preventive strategies.(1) Some of this interest has been, no doubt, driven by the development of drugs to treat erectile dysfunction in men, and the subsequent focus of biomedical industries on developing treatments for a range of sexual complaints. There are also generational factors at work here, with the aging 'boomer' cohort bringing a shift in attitudes and expectations towards what late life might look like.(2)

Studies in the US,(3) the UK,(4)(5) Finland,(6) Sweden,(7) Australia(8) and other countries(9) have repeatedly demonstrated that older adults remain interested in and capable of sexual activity across the life span. Yet tired stereotypes of older people as asexual (or inappropriately sexual) persist. At the same time, a new stereotype — the 'sexy senior' — who demonstrates their success in aging by remaining youthfully attractive and sexually active has emerged. Neither of these contrasting images provides a good basis for promoting sexual health and sexual rights for older people.

According to the World Health Organization, sexual health is:

… …a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.(10)

There remain significant gaps in our knowledge of, and willingness to address, issues related to older peoples' sexuality and sexual health. This Cyberounds® addresses a range of issues related to aging and sexual health, with an emphasis on recognizing sexual diversity and reaffirming sexual rights for older adults. The first half of the program will review the history and limits of the medicalization of later life sexuality, and the second half will review the current state of knowledge and its gaps.

The Medicalization of Late-life Sexuality and Its Limits

The degree of medical importance accorded to age as a cause for sexual decline has varied historically. Common wisdom in the late 19th and early 20th centuries often cited the age of 50 as that at which one should renounce physical love as one's desires and powers waned. It was considered to be nature's plan, for both men and women, to link peak sexual desire and power to the reproductive years, and these, once past, signaled a new, sexless phase of life.(11)

Until the mid-20th century, medical science offered a conflicting set of resources. It enumerated the pathologies of age, and held out the promise of treating some of its most serious maladies, but when it came to sexual decline, had little to offer beyond the counsel of adjustment. It was not until new psychological explanations gained traction in the mid-20th century that sexuality was added to gerontology's ideals of positive aging. Key sexological contributions from those such as Kinsey(12)(13) and Masters and Johnson,(14)(15) among others, stressed that sexual activity may be enjoyed across the full span of life, and that sexuality was a healthy component of successful aging. While men and women alike were told they may need to adjust to some physical changes associated with aging, they were nonetheless enjoined to learn to enjoy sex more as they matured, focusing primarily on intimacy and less on performance.

In the 1980s, a different turn was taken, as new developments in urology severed the mechanism of penile erection from any sort of tactile or emotional stimulation, conceptualizing it as a strictly physiological event. This trajectory of urological research culminated in the development of oral medications to treat erectile dysfunction.

When Viagra was introduced to the US market in 1998, both the popular media and the medical establishment hailed it as 'revolutionary.' Within months of its approval, millions of prescriptions had been written, a number of mass-market paperbacks hit the stands, stories abounded in the mainstream media, it became the subject of countless comedy monologues and cartoons, and hundreds of internet sites emerged promising discrete online ordering and home delivery. As one of those mass-market paperbacks crowed, "Now you can have sex when where and how you want, dependably and reliably, even if you're 100 and your partner's 102."(16)

It would be difficult to discuss aging and sexuality without at least acknowledging the impact of the development of sexuo-pharmaceuticals, as these have become closely associated with the treatment of age-related sexual dysfunctions. Viagra, of course, became a global blockbuster, new erectile drugs such as Levitra and Cialis have come to market, but the search for an equivalent drug for women has been elusive.

Despite the media penchant for calling Flibanserin (recently recommended by an FDA panel for approval) "the pink Viagra," there is no pharmaceutical equivalent to Viagra for women which addresses the vascular mechanisms of sexual arousal. Flibanserin is a re-tooled antidepressant, which must be taken daily and with a number of potentially unpleasant or risky side-effects, for very limited potential benefits (an increase of about .05 satisfactory sexual encounters per month).(17) There has also been renewed interest in testosterone therapy, but its efficacy and safety in treating sexual problems in either men or women remain controversial.(18)

Clinical and therapeutic perspectives which rely on a narrow biomedical understanding of sexuality — and more specifically, heterosexuality — have limited perceptions of sexual health in relation to age. Like the broader concept of 'public health,' sexual health is a social construct whose meaning is derived from particular social, cultural, historical and political contexts. Once defined as reproductive health and absence of sexually transmitted disease, sexual health has become increasingly focused on sexual desire and performance.(19) But when sexual health in relation to aging is so closely associated with particular kinds of sexual capacities, based on youthful, heterosexist standards, there is an implicit message of risk and decline in the absence of intervention.(20)(21)(22)(23)

To summarize, while sexual decline in both men and women was once assumed to be an inevitable consequence of growing older, this assumption has now been reversed. Changing sexual capacities previously associated with 'normal' aging are now pathologized as sexual dysfunctions that require treatment. As populations age, the prevalence of sexual dysfunction and the anticipated market for pharmaceutical solutions are predicted to increase dramatically. The dominance of this biomedical narrative suggests that the discourse of sexual rights for older people, as this has intersected with that of sexual health, risks being overly "product and medicine driven."(24) The overriding message is one of opportunities for rehabilitation to permit the ongoing performance of penile-vaginal intercourse. Little attention has been paid to prevention of sexually transmitted infections, despite recognition that older adults are now accounting for a growing proportion of new infections, and almost entirely absent is discussion of non-heterosexual relationships in later life.

Finally, while the new celebration of 'sexy seniors' is, in many ways, a development to be applauded, recognizing as it does a capacity for pleasure and intimacy which does not end with the flush of youth, the alternatives of an asexual old age and the "sexy oldie" discourse do not provide much of a range of positions, nor do they resonate with what qualitative research suggests about older peoples' experiences.

We will now review some of the key findings of contemporary research on aging and sexuality, and then outline two key areas where significant gaps in knowledge remain: the sexual health needs of LGBT elders, and STI prevention in older adults.

What Do We Know About Seniors and Sex?

It is only recently that major studies of sexual behavior began to include older respondents. In earlier iterations, both the National Health and Social Life Survey in the US(25) and the British National Survey of Sexual Attitudes and Lifestyles(26) excluded those older than 59! In the past decade, however, several well-publicized studies have investigated the sexual activity of those as old as 94.(3)(4)(5)(27)(28)(29)(30) Key findings from these surveys include the following:

While large-scale surveys such as these have been invaluable in putting issues of sexuality and aging on the health promotion agenda, qualitative research has been important in painting a more complex picture. For example, the documented decrease in the frequency of sexual activity among older people may not be reflected in decreased relational satisfaction,(32)(33) nor are changes in sexuality experienced necessarily cause for distress.(34)

Research on Viagra users and their partners, for example, has shown a far from uniformly positive reception.(35)(36)(37)(38) While many men can and do use erection drugs, others cannot or do not wish to. Some partners may welcome the prospect of more penetrative sex, others may not. Some complain that there are new pressures to be sexual on demand once the pill has been taken, others (especially older women) regret the renewed emphasis on penetrative sex as the main event. And given that almost half of prescriptions for erection-enhancing medications are not renewed, it's clear that they haven't acted as 'magic bullets' for all men.(39) A number of studies have demonstrated that penetrative sex may not dominate the repertoire of older individuals, who can be both inventive and playful in their intimate encounters.(40)(41)

Recognizing Sexual Diversity

As noted above, one of the shortcomings of biomedically-driven models of sexuality has been its focus on penile-vaginal intercourse in the monogamous, heterosexual couple as the normative form of sexual expression. While this certainly limits our understanding of diversity among those who identify as heterosexual, it fails to even put non-heterosexuals on the map. Thus, even less is known about sexuality and aging in lesbian, gay, bisexual and transgendered (LGBT) individuals than in those who identify as heterosexual.

Though difficult to precisely represent the proportion of older adults who identify as LGBT, estimates suggest that this is between 3% to 8% of the US population.(43)(44) An increase in the aging population, coupled with increasing LGBT social and legal acceptance, will likely mean that LGBT elders will become more numerous and more visible. While the invisibility of LGBT elders is certainly related to the historical de-sexualization of the senior population more generally, just recognizing — or even celebrating — the sexuality of older adults is not sufficient to encompass their concerns. As one advocate points out, sexuality is only one part of LGBT identities, "the social meaning attached to sexual orientation and gender identity permeates even the most mundane aspects of an individual's life."(45)

While LGBT elders will share many of the same sexual health concerns with their heterosexual counterparts, they may also present some unique needs, and historical and social context are particularly important in understanding these. Many in this population matured sexually in an era when same-sex relationships were not only stigmatized but criminalized, making invisibility a key survival strategy. Someone turning 65 in 2015 was born in 1950, which means that when they came of age, homosexuality was still included in the DSM as a psychiatric disorder, and medical interventions may have included aversion therapy and electroshock treatments aimed at 'curing' them.(45) It is not surprising, then, that many stayed 'in the closet'.

The experience of discrimination may have consequences not only for health, but for access to necessary services. Research has shown that LGBT elders are not confident in relying on health care systems that have historically discriminated against them, and many are not willing to disclose their sexual identity to their health care providers. Even some LGBT elders who have been living openly, "now find themselves returning to the closet to avoid anti-LGBT bias on the part of service providers." Studies suggest that anywhere from 20-30% of LGBT older adults do not disclose their sexual or gender identity to their physician.(46)(47)

In a review of multiple focus group studies with LGBT older adults, it was reported that medical/health care needs were the primary source of concern expressed by participants.(48) Their concerns mirrored the findings of previous research,(49) revealing patterns which suggested lower rates of preventive health care and screening, and higher reported difficulties in obtaining care. Focus group participants also shared their frustration with the assumption of heterosexuality among health care providers, including when sexual histories were taken. Half of the participants reported that their physicians did not discuss sexual activity at all.

In one UK study,(47) older lesbian, gay and bisexual people were twice as likely as their heterosexual counterparts to expect to rely on external care services (including physicians, health care aides and social services) to meet their needs as they age, but at the same time expressed low levels of confidence that these providers would be able to understand their needs. As one respondent put it: "Although things are improving, there is still a lot of ignorance at least, homophobia at worst, among health and social care people". Several organizations in the UK and the US have developed practice guidelines for taking sexual histories and identifying the sexual health needs of sexually diverse patient groups,(50) and these should be adapted for the specific needs of older patients.

Once among the most invisible of older adults, the special challenges that may face transgendered persons in later life have recently been highlighted by the very public transition of Caitlin Jenner, at 65, as well as similar fictional portrayals in the critically-acclaimed television series Transparent. Transgender elders may have special health care needs related to both physical and social aspects of aging. Some transgendered individuals may identify as heterosexual; others may identify as lesbian, gay or bisexual, suggesting that these needs may overlap with those larger groups. However, they also face some issues specific to gender transition. For example, little is known about the long-term effects of life-long hormone treatments or other medical interventions related to physical transition. Transgender individuals also vary in the extent of surgical reassignment they have undergone. There is no doubt that the sex-segregated nature of most long-term care facilities may make the prospect of residential care especially difficult for transgendered elders to contemplate navigating.(51)

It is important to keep in mind that, like their heterosexual counterparts, LGBT elders are not a homogenous group, but are shaped by gender, race, geographical location, socioeconomic status and age, among other factors. In general, a perspective on sexual health that embraces sexual diversity suggests that whatever their sexual or gender identity, older adults are entitled to express their sexuality and to have access to information and services which will enable them to do so in a personally fulfilling and safe manner.

STI Rates and Prevention in Older Adults

One aspect of aging and sexuality, which has received insufficient attention, is prevention of sexually transmitted infections. A number of factors have contributed to the lack of discussion with, and paucity of information provided to, older adults on this topic. First, ageism has continued to fuel the assumption that older adults are not sexually active, or at least not engaging in risky sexual behaviors, and are thus not a population that is of concern in this respect. This is reflected in the only recent collection of population-level data on sexual behaviors in older people. Second, generational differences mean that many of today's seniors did not benefit from widely available sex education. Older adults are, on the whole, less aware of the risk factors for HIV than younger people, and more likely to engage in risky sexual behaviors, including unprotected intercourse.(52)(53) Older heterosexuals, for example, who enter into new relationships after finding themselves single in later life may not see the need for condom use when pregnancy is no longer a concern.

However, research shows that rates of sexually transmitted infections, including syphilis, chlamydia, gonorrhea and HIV/AIDS have rapidly increased among older people in recent years.(54)(55) STIs are also likely to be diagnosed at later stages in older people — perhaps because they perceive themselves as being at low risk and/or because of embarrassment in requesting testing. Practitioners, because they may not perceive older patients as at risk for STIs, may also ignore symptoms or delay diagnoses.(56)(57)

As with other age groups, risk behaviors vary by gender and sexual identify, with men who have sex with men remaining the largest at-risk group.(58) However, HIV rates among heterosexual women over the age of 55 have been rapidly increasing.(55) A number of studies have suggested that older women in particular do not see themselves at risk for HIV,(3)(59)(60) yet women may be at particular risk for infection, partly due to physiological changes associated with menopause, such as thinning and drying of vaginal tissues that make them more susceptible.(56)(57) One study found that only 2% of older women were aware that they had a greater risk of contracting HIV than a younger woman in any given episode of sexual intercourse.(61) Very few of the women in this study (3%) had received any HIV-prevention education from their physicians.

Addressing the Sexual Health Needs and Sexual Rights of Older People

As noted above, older people are often reluctant to raise their sexual concerns with health care providers. There is also evidence that the latter are usually unwilling (or unprepared) to initiate discussions about sexuality.(62)(63)(64) Old myths and stereotypes about aging and sexuality may lead some to feel that sexuality is not a relevant topic for discussion with their older patients. Some practitioners report feeling that their medical education did not prepare them for addressing sexual health concerns in later life.

Even though many medications that older people may be taking have potential sexual side effects, patients report that their doctors frequently did not mention these, perhaps because they did not feel they would be of concern to older patients.(65) As researcher Sharron Hinchliff notes, "If doctors leave it to older adults to ask about their sexual concerns, and older adults leave it to their doctors to raise the issue, then a clear unmet need exists."(66) In working towards meeting this need, several points are worth reiterating.

First, it is essential to recognize the limits of thinking about sexuality through a biomedical lens. A more productive way for health care providers to address sexual concerns, whether or not medical remedies are prescribed, may be to consider the broad range of socio-cultural, interpersonal and psychosocial factors that shape sexual experience for both men and women across the life course.(67)

Second, sexuality remains important to older adults, but this is far from a homogenous group. Non-judgmental openness to and recognition of diversity — of age, sex, gender, sexual identity, relationship status, sexual activity preferences, cultural background and context — should be the starting point for productive discussions about sexuality.

Third, necessary and appropriate sexual health services must be made available and offered to older patients, including information on sexual expression and sexual pleasure, testing and prevention information for STIs, and referrals to other community and counseling supports as required.

Finally, while it is important to recognize that sexual activity may indeed be linked to healthy and 'successful' aging, there is a risk that the recent celebration of 'sexy seniors' may create new pressures for older adults to meet unrealistic standards of sexual function. Sexuality may change with age, but not necessarily in ways that mean decline, or produce distress.