Recent studies suggest that most older adults maintain sexual interest well into late life; many, however, experience sexual dysfunction. This article provides psychiatric practitioners with current information regarding sexuality and aging, as well as psychiatric and systemic medical comorbidities and sexual side effects of medications. Practice guidelines for assessing and managing sexual dysfunction have been developed for use in many medical specialties, and such guidance would be welcome in psychiatric practice.
This article addresses the myth of “geriatric asexuality” and its potential impact on clinical practice, the effects of age-related physiological changes on sexual activity, the importance of sexuality in the lives of older adults, and sensitive questions clinicians can pose about geriatric sexuality. We also will discuss:
• the importance of including a sexual assessment in the comprehensive psychiatric evaluation
• recognizing sexual dysfunction
• providing appropriate management within a multi-disciplinary, collaborative approach.
Sexuality after 65
Regardless of age, sexual activity can provide a sense of comfort and elicit a positive emotional and physical response.1 Hillman2 defined human sexuality as any combination of sexual behavior, emotional intimacy, and sense of sexual identity.
Sexuality in the aging population generally is an understudied area, obscured by the myth of “geriatric asexuality” and subject to numerous psychosocial variables.1 Previous research, focused on a biological perspective of sexuality, has largely overlooked psychological and social influences.3 It has been assumed that, with age, physical and hormonal changes or chronic illness ordinarily reduce or eliminate sexual desire and sexual behavior.3 However, the majority of older adults (defined as age ≥65) report a moderate-to-high level of sexual interest well into late life.1,3
Sexual function remains a subject often neglected in psychiatry. Sexual dysfunctions, as described in the DSM-5,4 do not include age-related changes in sexual function. In addition to physiological changes, sexual difficulties can result from relationship strain, systemic medical or psychiatric disorders, and sexual side effects of medications.
CASE REPORT
Mr. C, age 71 and married, is being treated for a major depressive episode that followed a course of shingles and persistent postherpetic neuralgia. Medications are: escitalopram, 20 mg/d; pregabalin, 150 mg/d; and ramipril, 5 mg/d. Mr. C is physically active and involved in social activities; he has no substance use history. He attends clinic visits with his wife.
Mr. C reports that despite significant improvement of his depressive and pain symptoms, he now experiences sexual difficulties, which he seems hesitant to discuss in detail. According to his wife, Mr. C appears to lack sexual desire and has difficulty initiating and maintaining an erection. She asks Mr. C’s psychiatrist whether she should stop her estrogen treatment, intended to enhance her sexual function, given that the couple is no longer engaging in sexual intercourse.
Mr. C admits to missing physical intimacy; however, he states, “If I have to make a choice between having sex with my wife and getting this depression out of my head, I’m going to pick getting rid of the depression.” Mrs. C says she is becoming dissatisfied with their marriage and the limited time she and her husband now spend together. Mr. C’s psychiatrist suggests that Mr. C and his wife undergo couples counseling.
Physiological changes with aging
In both women and men, the reproductive system undergoes age-related physiological changes.
Women. In women, the phase of decline in ovarian function and resulting decline in sex steroid production (estradiol and progesterone) is referred to as the climacteric, with menopause being determined retrospectively by the cessation of a menstrual period for 1 year.5
Menopausal symptoms typically occur between age 40 and 58; the average age of menopause is 51.6,7 Both estradiol and progesterone levels decline with menopause, and anovulation and ovarian failure ensue. A more gradual decline of female testosterone levels also occurs with aging, starting in the fourth decade of life.8
Clinical manifestations of menopause include vasomotor symptoms (ie, “hot flushes”), sleep disturbances, anxiety and depressive symptoms, decreased bone mineral density, and increased risk of cardiovascular disease.6,7 Loss of estrogen as well as continued loss of testosterone can result in dyspareunia because of atrophy and decreased vulvar and vaginal lubrication, with sexual excitement achieved less quickly, and a decreased intensity of orgasm.7
Men. Research has shown that testosterone levels are highest in men in the second and third decades, with a subsequent gradual decline.9 Older men with a low testosterone level are described as experiencing “late-onset hypogonadism,” also known by the popularized term “andropause.”10 This is attributed to decreased activity at the testicular and hypothalamic levels.10
Nonetheless, only a small fraction of older men with confirmed androgen deficiency are clinically symptomatic.11,12 Low testosterone is associated with decreased libido; it can hinder morning erections, contribute to erectile dysfunction, and result in erections that require physical stimulation.13