Sexual Health and Wellness of Aging Adults

The information on aging and sexuality has been written by Action Canada for Sexual Health and Rights and Shelley Taylor, Certified Sexual Health Educator. For full document and other topics from Sexual and Reproductive Health Week 2019, please visit the Action Canada website.

What are we talking about when we talk about aging and sexuality? When does “aging” begin? This section explores the transition from adulthood to older adulthood and end of life. It features information and discussion prompts on experiences people may have around sexuality, sexual function, and sexual health as they grow older.

We are sexual beings throughout our entire lifespan.

Our sexuality includes our feelings, values, ideas, and experiences related to our individual sexual preferences. It is also our needs as individuals to communicate love, tenderness, and desire towards others, as well as express ourselves as sexual beings. Our sexuality doesn’t turn off once we hit the golden years!

Despite a lack of representation of aging people and their sexuality, sexuality remains an important aspect of our lives, our relationships, and our health. Even with lots of changes to sexual function, desire, ability, and health, we have the right to control our bodies and sexuality, to be free of discrimination, violence and coercion, and we still have a right to information and to health.

Sexual health is not just the absence of disease; it’s an essential and positive dimension of being human. For some of us, talking about sex and sexual health is difficult or uncomfortable but our overall wellness includes dimensions of physical, emotional, mental, and social well-being in relation to our gender and sexuality.

There are important ways in which we can nurture our sexual health and well-being, even when we face challenges. The first step is to get informed and have conversations about our sexual health with our loved ones and with our healthcare providers.

The Sexual Health and Wellness of Aging Adults

We can’t think of health without thinking about the social determinants of health. Social determinants of health are the conditions in which people are born, grow, live, work, and age. They are shaped by the distribution of money, power, and resources at local, national, and global levels.

These determinants include race, impacts of colonialism on Indigenous peoples and communities, gender, adverse childhood events, or poverty to name a few. They affect people’s health more than diet, physical activity, smoking, and excessive drinking. Social determinants of health affect our access to resources like housing, money, healthy foods, public transportation, safe jobs, clean air and water, and childcare. They also affect our access to healthcare and our access to support networks. Keep in mind that each of the following considerations is strongly informed by our social and economic situation.

The following issues can profoundly impact our sexual health and well-being and our ability to maintain optimal health as we age. We have to carefully think about them as we navigate aging (they are important for our support systems and healthcare providers too).

As we age, nurturing our sexual selves, our sexual expression, and our sexual health continues to be an important and positive aspect of our overall health. While aging can bring real challenges that we must contend with and should feel informed about, we should also celebrate the joyful, pleasure-focused expression of sexuality.

Sex, Pleasure, and Sexual Function

Most of us want and need to be intimate and experience closeness and touch as we grow older. For many, this includes having an active and satisfying sex life. As we age, that may mean adapting sexual activity to accommodate physical and health changes.

There are many different ways to have sex and be intimate, alone or with a partner. We are never too old for a happy and healthy sex life. The expression of your sexuality can include many types of touch or stimulation. Some of us may choose not to engage in sexual activity and that’s also normal.

Many people, young and old alike, are surprised at the idea of remaining sexually active in their sixties and beyond. It is frequently assumed that people lose their sexual desires or are physically unable to perform. For many of us, the ability to remain sexually active is a major concern as we age. Some of us fear losing our sexual prowess, while others might feel like expressing sexual interest could seem undignified. Some of us may be comfortable with our sexuality but have to deal with family members, children, and grandchildren who disapprove, feel uncomfortable, or openly discourage expressions of sexuality.

Our sexuality is a way to express passion, affection, admiration, loyalty, and to feel pleasure. As we age, it can also become a way to affirm physical functioning, maintain a strong sense of identity, nurture self-confidence, and prevent anxiety.

The way we have sex may change but it is possible to continue having a joyful, healthy sex life even if it means adapting the way we think about certain sexual activities and having to seek more support from our loved ones and our healthcare team.

What are Some Common Changes?

Aging brings on physical changes in all people. These changes sometimes affect the ability to have and enjoy sex. Here is a list of common changes.

Changes to the Vagina

The vagina can shorten and narrow with age. The vaginal walls can become thinner and a little stiffer. Most of us will have less vaginal lubrication and it may take more time for the vagina to naturally lubricate itself. These changes could make certain types of sexual activity, such as vaginal penetration, painful or less desirable. Vaginal dryness can become a significant issue and cause pain and discomfort and using water or silicone-based lubricants can help make sex more comfortable. Using high quality condoms, ones that are thin, strong, and come in the right shape and size, can make a big difference. Perimenopause and Menopause

Perimenopause means “around menopause” and refers to the natural transition to menopause, marking the end of the reproductive years. Perimenopause is also called the menopausal transition.

Perimenopause starts at different ages for different people. Signs of approaching menopause, like menstrual irregularity or hot flashes, can start in our mid-forties but some people may notice signs as early as their thirties.

The level of estrogen in our bodies goes up and down unevenly during perimenopause. Our menstrual cycles may lengthen or shorten and we may begin having menstrual cycles in which we don’t ovulate. The change in estrogen may also cause menopause-like symptoms such as hot flashes, sleep problems, mood disturbances, and vaginal dryness. Treatments are available to help ease these symptoms, so talk to your healthcare provider. After twelve consecutive months without a menstrual period, you have officially entered menopause!

Perimenopause and menopause are major life events. We deserve access to health information and support as we navigate and manage the changes they bring. Perimenopause and menopause can change our everyday life, how we relate to others, our sexuality, our body, our levels of energy, our mood, our mental health, and general well-being. Perimenopause and menopause’s mood swings and emotional impacts can be very difficult. Good mental healthcare during this time is important. Unfortunately, we rarely talk openly about menopause, making it hard for us to feel validated. This is especially true for who experience perimenopause and menopause.

Beyond the changes in our bodies, menopause can impact sexual function. Changes in estrogen and progesterone during menopause can cause vaginal dryness and discomfort, possible pain during intercourse because of skin becoming thinner and more brittle, recurrent urinary tract infections, loss of bladder control, and a decrease in libido. Sexual arousal and desire may also change; however, if you have satisfactory sexual intimacy before menopause, this will likely continue. Addressing sexual function issues to continue enjoying a happy healthy sex life is not out of reach.

Medical support such as hormone replacement therapy (HRT) is an option and can help reduce symptoms—some people may even experience an increase in sexual libido on HRT. You can also seek support from health professionals like naturopathic doctors, physiotherapists, pelvic floor specialists, and sex coaches. When bringing up your need or desire for HRT with your healthcare team, it is important to include sexual side effects in the conversation to ensure that any interventions also address sexual health issues.

Erectile Challenges/Dysfunction

Erectile challenges become more common as we age. Erectile dysfunction is the loss of ability to have and keep an erection. This means it can take longer to have an erection and it may not be as firm or as large as it used to be. It also means the loss of erection after orgasm can happen more quickly or it can take longer before another erection is possible. Erectile dysfunction is not a problem if it happens every now and then but talk to your doctor if it occurs often.

Dealing with erectile challenges can make us feel self-conscious, anxious, depressed, or angry, which in turn can impact sexual function. Different medical interventions and medications can help increase blood flow to the penis. Many people find therapy to be helpful, particularly when erectile dysfunction is caused by performance anxiety. Open communication is key—we can adapt the sex we’re having and find different ways to remain intimate even when we’re experiencing erectile dysfunction.

Talk to your healthcare providers for support and discuss ways to make sex easier and more comfortable. Remember: accessing healthcare for the changes we go through as we age, including sexual changes, is a common and normal experience.

What can Cause Sexual Problems?

Some illnesses, disabilities, medicines, and surgeries can affect our ability to have and enjoy sex. We are entitled to positive affirming care from our healthcare team to support us in regaining or maintaining sexual function and to help us nurture our sexual health even in the face of major challenges.

Here are some issues that can cause sexual problems.

Incontinence

Incontinence, the loss of bladder control or leaking of urine, is more common as we grow older. This is especially true for those of us who have experienced pregnancy and birth earlier in life. Extra pressure on the bladder during sex can cause us to lose urine and this can lower our desire to have sex. Incontinence can usually be treated. Changing sexual positions or emptying the bladder before and after sex can help. Consulting a pelvic floor physiotherapist can also help with incontinence.

Arthritis

Joint pain due to arthritis can make sex uncomfortable. Exercise, medications, and sometimes joint replacement surgery may help relieve this pain. Rest, warm baths, and changing the position or timing of sexual activity can help.

Using pain medication

Some pain medication can interfere with sexual function. Sometimes changing the timing of when you take the medication can help. Always talk with your doctor if you have side effects from any medication. Your healthcare team should look at the whole picture when finding the best treatment for you.

Dementia

Some people with dementia will experience an increase in their desire for sex and physical closeness but might not have the ability to judge what is appropriate sexual behaviour. Those with severe dementia might not recognize their partner(s) but still desire sexual contact and might try to initiate it with someone else. It can be confusing and difficult to know how to handle this situation. Talking with a doctor, nurse, or social worker with training in dementia care may be helpful.

Diabetes

Diabetes can cause erectile dysfunction. In most cases, medical treatment can help. Diabetes can increase the risks of having vaginal yeast infections, which can cause itching and irritation and make sex uncomfortable or undesirable. Yeast infections can be treated.

Heart disease

Heart disease is incredibly common, which makes talking about sex in the context of heart disease important. Sex after a heart attack can be impacted by many things such as medications that may affect the ability to maintain an erection or the inability to use certain drugs like Viagra or Cialis depending on what medications you are on (for example, nitrates). Keep an eye out for chest pain, dizziness, or shortness of breath while having sex with heart disease. If you’ve had a heart attack, speak with your doctor about when you can resume having sex or how you might modify the sex you are having (if required), depending on how you’re feeling. For more information, read The Advanced Cardiovascular Life Support Training Centre’s Is There Sex After a Heart Attack? (The short answer is YES!). If you’re feeling anxious about resuming sex after a cardiac event, open communication with your partner or modifying the ways you are intimate can help.

Stroke

A stroke can affect the ability to have sex. If the stroke left someone with ongoing weakness or paralysis, changes in position and/or medical devices can help people have sex. Some people with paralysis from the waist down are still able to experience orgasm and pleasure. Even when people lose sensations in some parts of their bodies, closeness, and touch as well as sensual pleasures remain important.

Surgery

Surgeries involving breasts or genital area can impact sexual function. That said, most people do return to the kind of sex life they enjoyed before surgery.

Hysterectomy is surgery to remove the uterus because of pain, bleeding, fibroids, or other reasons, including gender-affirming reasons. Often, when an older person has a hysterectomy, the ovaries are also removed. The removal of those organs and the impacts it can have on hormonal balance can leave people and their partners concerned about their sex lives. If you have any concerns about the changes you might experience with a hysterectomy, it is important to talk with your healthcare team.

Mastectomy is surgery to remove all or part of the breast because of breast cancer. This surgery may cause some people to lose their sexual interest or may leave them feeling less desirable or attractive to their partners. Some people opt to go for breast reconstruction and some don’t. Some people experience nerve pain. In all cases, support is important to ensure a positive recovery.

Prostatectomy is the surgery that removes all or part of the prostate because of cancer or because it was enlarged. It may cause urinary incontinence or erectile challenges. It is important to bring up concerns around sexual function with your healthcare team.

Medication

Some medication can cause sexual problems. These include some blood pressure medication, antihistamines, antidepressants, tranquilizers, Parkinson’s disease or cancer medications, appetite suppressants, and medication to treat ulcers. Some can cause erectile dysfunction or make it hard to ejaculate. Some drugs can reduce sexual desire, cause vaginal dryness, or cause difficulty with arousal and orgasm. Your healthcare team can help you find the right medication for your health and well-being.

Cancer

Cancer can develop at any age but is much more common in older people. Almost 9 in 10 cancer cases are in people aged 50 and over, with about a third in people aged over 75. A cancer diagnosis and treatment can impact our overall health and well-being. It changes how we relate to others and our bodies and we may have to navigate new disabilities or challenges. Many may also experience sexual side effects. For instance, gynecological, colorectal, and anal cancers may make penetrative sex more difficult and/or impossible, while treatment such as chemotherapy can impact lubrication, libido, sexual interest, and energy levels. Breast cancer, which may result in mastectomy, as well as other cancers involving physical changes, can impact how we relate to our bodies. Maintaining a good quality of life means paying attention to our sexual health well-being, so receiving the support of a healthcare team that considers sexual health as an important part of our health when exploring treatment options can play a major role in a holistic and affirming approach to care.

HIV

Many of the normal challenges of aging can be accelerated by HIV because the virus activates the immune system and inflammation processes in the body. This can result in weakened bones, loss of muscle mass, and liver, cardiovascular, and kidney disease; these can be worsened by the side-effects of antiretroviral treatment. Having a team of healthcare providers that are specifically knowledgeable about HIV can help older adults living with HIV have happy, safe, and sexual lives. As with other aging adults, it’s important for older adults living with HIV to remain socially connected—many local AIDS service organizations (ASOs) offer programming so that folks can connect with one another.

Getting it on: Some tips

Many of the changes that can take place in and around our genitals as we age are caused by a lack of blood flow, muscle loss, and hormonal changes. Encouraging maximum blood flow to our bits, ideally on a regular basis, is an excellent way to keep tissue healthy and maintain an interest in sexual play. Here’s what you can do:

1. Moisturize and/or massage your genitals daily with coconut oil, silicone lube, or a water-based lube.

2. Do Kegel exercises (flexing and tightening of the pelvic floor muscles using exercises). A pelvic floor specialist can help you figure out how best to strengthen these muscles.

3. Use vibration and/or suction to increase blood flow and sensation. This can be great for any erectile challenges as well.

4. Encourage extended play-time before penetration.

5. Do penetrative exercises with a dilator or smooth dildo to help keep vaginal or anal tissue elastic and pliable.

6. Place a warm washcloth on the genitals before play. This will bring blood to the surface and relax the tissue. A bath would work in a similar way but can be too drying for some.

7. Use erotica, exploration, experimentation, and creative fantasizing. Variety can help keep things interesting.

Do I Still Need to Wrap it Up?

The short answer is yes. Age doesn’t protect us from STIs, which are very common for those of us who are sexually active. STI rates among older adults are increasing. Between 2002 and 2011, chlamydia rates in people over 50 tripled, syphilis rates increased five times, and gonorrhea rates doubled. In 2011, people over 50 represented 18.2% of new positive HIV tests in Canada. Baby boomers are considered high risk for which they may have contracted before blood donations was actively being tested. Researchers estimate that up to 70% of people born between 1956 and 1975 who have Hepatitis C are unaware of their infection status.

Many infections are asymptomatic or, if symptoms are present, they can mimic the normal signs of aging and can easily be overlooked. Age-related changes like decreased vaginal lubrication and thinning of vaginal walls and anal tissue can also increase the chances of getting an STI. The lack of sexual health information where older adults gather or live is a contributing factor in the rising rates of infections and delays to diagnose and treat. Incorporating routine testing is important at all ages, even if you don’t experience any symptoms of an STI.

Aging with Pride

When we talk about aging and sexual health, we need to talk about two-spirit, lesbian, gay, bisexual, trans, and queer seniors and the unique barriers they face in accessing housing, healthcare, long-term care, and other needed services.

Many health and social service providers intentionally avoid conversations around sexuality and gender identity because they believe that a patient’s sexuality or gender identity has “nothing to do with” the care they deliver. Other healthcare providers might assume that all patients are heterosexual and cisgender, risking misunderstanding, discrimination, erasure, and mistreatment.

Aging LGTBQ2S+ folks face significant barriers to receiving healthcare, including healthcare providers who are uninformed about their sexuality or gender identity or actively hostile towards LGBTQ2S+ folks. This means that many people avoid accessing healthcare services (including palliative care services) because they anticipate stigma or discrimination or don’t believe support services would meet their needs. Concerns that loved ones will not be recognized as next of kin is also a major barrier to healthcare. Aging LGTBQ2S+ folks are often invisible in services, policies, and research. For example, policies within hospitals may limit visitation to only biological family or married spouses, leaving out chosen family, unmarried partners or anyone who doesn’t “fit the bill.” They end up having to fight for their right to visit their loved ones at time of hospitalization.

Studies on LGBTQ2S+ aging outline three specific generations of aging LGBTQ2S+ people:

• The Invisible Generation: those who came of age during the Great Depression and World Word II and who were largely left out of public discourse.

• The Silent Generation: those who came of age during a period of great persecution of people who challenged sexual and gender norms. Their identities were seen as threats to national security and many aspects of sexual expression were criminalized and/or classified as psychiatric disorders.

• The Pride Generation: those who came of age during a time of significant social change, kicked off by the Stonewall riots and civil rights movement. LGTBQ2S+ folks became more visible in the public and political spheres, beginning the process of decriminalization of their gender and sexuality. This generation is also marked by the AIDS pandemic.

While there is a steadily growing number of social support services for LGBTQ2S+ youth and adults, LGBTQ2S+ seniors have fewer spaces to gather. For those who require long-term care, few options exist for affirming living. This is exacerbated by the fact that LGBTQ2S+ seniors are more likely to avoid accessing healthcare until later in life, to experience financial difficulties, and therefore may access fewer social services.

Sexuality at End of Life

In the terminal stages of illness and at the end of life, sexuality is often not considered important by healthcare providers. The need or ability to participate in sexual activity may fade in the terminal stages of illness but the need for touch, intimacy, and relationships doesn’t necessarily vanish. People may in fact suffer from the absence of loving and intimate touch in the final months, weeks, or days of life.

It is often assumed that when life nears its end, people and couples are not concerned about sexuality. This attitude is a result of little information and visibility on sex, death, and how they intersect; however loving relationships, intimacy, and sexual contact are important even during terminal illness. Sexuality can be a key component of holistic care and overall quality of life and should be prioritized by caregivers and healthcare providers to improve the well-being of dying people. Sexuality can also provide closeness and/or closure at end of life.

Physical relationships may become difficult after receiving a terminal diagnosis, often because of how illness impacts the body. People can experience changes in their appearance and physical and emotional pain that affect both libido and sexual functioning. Relationships can also change as partners take on caregiving roles and tasks, which can impact intimacy and expressions of sexuality. This often happens at a time when individuals wish to strengthen relationships with the ones they love, so it’s crucial that healthcare providers and caregivers help facilitate expressions of intimacy and sexuality among patients and their loved ones.

One study explored how sexuality was experienced by palliative care patients. In this study, respondents identified sexuality as “emotional closeness” and noted that closeness frequently meant activities other than sex. Sexuality is diverse and includes different forms of sexual expression. In the end, sexuality is whatever it means to the patient. Caregivers should allow the person they are caring for to define sexuality on their own terms and practice it in ways that make sense for them.

Here’s what it looks like for a healthcare team to address the sexual needs of patients:

• Giving patients and their loved ones explicit permission to touch each other even at advanced stages of an illness.

• Becoming fierce advocates of patient privacy. In healthcare settings, this may mean advocating for single-occupancy rooms. When people receive care at home, they can be moved to common living spaces for the sake of easier access to care. This can make being intimate with a partner difficult. People can be encouraged to close doors when private time is desired.

• Giving permission to partners to lie with their loved ones in bed, even in palliative care. In most situations, kissing, stroking, massaging, and holding a terminally ill patient is unlikely to cause physical harm and can facilitate relaxation and decrease pain.

• Encouraging loved ones to participate in their partner’s care routine can be a way to encourage touch and closeness.

• Normalizing and validating sexual health issues as normal and legitimate health concerns during terminal illness and/or end of life.

• Initiating conversations to provide an opportunity for patients to discuss their needs and desires.

• Avoiding showing discomfort when discussing sexuality. People can sense this discomfort and will shy away from talking about their sexuality-related concerns.

• Treating individuals as people—not as their disease or illness! This includes sexuality as a key component of their holistic wellness.

• Ensuring the use of inclusive terms when discussing family, loved ones and romantic partners. This can be as simple as using the word “partner” or “partners” instead of presuming heterosexuality, monogamy, and/or assuming that individuals are married.

A healthcare team dedicated to a holistic approach to end of life care can help devise specific strategies to continue sexual activities. Supporting patients and couples to see themselves as sexual in the face of terminal illness is an important first step. Offering the patient/couple the opportunity to discuss sexual concerns or needs validates their feelings and may normalize their experience.

The PLISSIT Model is used in sex therapy and can be useful for introducing sexuality and sexual health discussions within clinical care. There are four key components of this model:

1. Permission: show a willingness to discuss sexuality related topics and include an open-ended invitation to further the conversation (e.g. “those in similar situations have expressed concerns about intimacy and sex. What concerns are you having?”).

2. Limited Information: provide brief education to patients and partners regarding common sexual side effects associated with the illness and its treatment.

3. Specific Suggestions: give concrete suggestions to patients on how they may cope with effects of the illness. This is important whether or not individuals are in relationships and may involve discussion on how sexual pleasure was achieved prior to the diagnosis.

4. Intensive Therapy: provide referrals to a sex therapist or relationship counselor if it is required or helpful for the individual.

If you are currently experiencing a terminal or life-altering illness or injury, here are some useful questions to ask yourself when advocating for healthcare that acknowledges your right to be intimate:

• How important is sexual intimacy to you? How important is it to your partner(s)?

• What helps you feel close and connected with your partner(s)?

• What changes have you noticed in your sexual functioning?

• How has this illness or injury impacted your sexual relationship with your partner(s)?

• What kind of supports could help you maintain physical closeness with your partner(s)?

You have a right to pleasure and closeness.

RESOURCES

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