sexual psycology

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International Journal of Sexual Health

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Seventy-Five Years Old and Still Going Strong: Stability and Change in Sexual Interest and Sexual Enjoyment in Elderly Men and Women Across Europe

Bente Traeen, Aleksandar Štulhofer, Tanja Jurin & Gert Martin Hald

To cite this article: Bente Traeen, Aleksandar Štulhofer, Tanja Jurin & Gert Martin Hald (2018) Seventy-Five Years Old and Still Going Strong: Stability and Change in Sexual Interest and Sexual Enjoyment in Elderly Men and Women Across Europe, International Journal of Sexual Health, 30:4, 323-336, DOI: 10.1080/19317611.2018.1472704

To link to this article: https://doi.org/10.1080/19317611.2018.1472704

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Seventy-Five Years Old and Still Going Strong: Stability and Change in Sexual Interest and Sexual Enjoyment in Elderly Men and Women Across Europe

Bente Traeena, Aleksandar �Stulhoferb, Tanja Jurinc and Gert Martin Haldd

aDepartment of Psychology, University of Oslo, Oslo, Norway; bDepartment of Sociology, University of Zagreb, Zagreb, Croatia; cDepartment of Psychology, University of Zagreb, Zagreb, Croatia; dDepartment of Public Health, University of Copenhagen, Copenhagen, Denmark

ABSTRACT Objective: The aim of this study was to test a conceptual model of retrospectively assessed change in sexual interest and sexual enjoyment in the past 10 years among coupled older adults in Norway, Denmark, Belgium and Portugal. To which degree do structural influences, personal characteristics, and interpersonal factors predict the dynamics of sexual interest and enjoyment in partnered persons? Methods: Data were collected as a cross-sectional pos- tal survey, with national probability-based samples of the population aged 60-75 years recruited by phone registers in Norway (676 men and 594 women), Denmark (530 men and 515 women), Belgium ( 318 men and 672 women), and Portugal (236 men and 273 women). Results: Across countries, personal characteristics—primarily general health status—were the most important predictors of change in sexual interest and sexual enjoyment in men. Change in sexual interest and enjoyment among women (except for Portuguese women) was best predicted by interpersonal factors. Conclusions: Good health, an active sex life throughout the lifespan, direction of relationship, and feeling emotionally close to partner during sex are important factors in maintaining sexual interest and enjoyment among part- nered older adults in Europe.

ARTICLE HISTORY Received 8 January 2018 Revised 12 March 2018 Accepted 1 May 2018

KEYWORD sexual attitudes and behaviors; sexual development; cross-cultural studies; elderly sexuality

It is well documented that sexual activity and sexual satisfaction decrease as people age (Bell, Reissing, Henry, & VanZuylen, 2017; DeLamater, 2012; Field et al., 2013; Herbenick et al., 2010; Hinchliff & Gott, 2011; Kontula & Haavio- Mannila, 2009; Laumann, Gagnon, Michael, & Michaels, 1994; Lee, Nazroo, O’Connor, Blake, & Pendleton, 2016; Lindau & Gavrilova, 2010; Lindau et al., 2007; Palacios-Ce~na et al., 2012; Schick et al., 2010; Traeen et al., 2018). However, rather than focusing on changes in sexual activity in aging individuals, Bell et al. (2017) suggested that it is the change in sexual interest and enjoy- ment that should be at focus. Further, it has been suggested that sexual interest and enjoyment is part of successful sexual aging, making the study of these outcomes even more important among older age cohorts (�Stulhofer, Hinchliff, Jurin, Hald, & Traeen, 2018).

The literature on stability and change in sexual interest and sexual enjoyment in older adults is sparse. Two nationally representative cohorts of 57- to 64-year-old adults in the United States were surveyed 10 years apart. Using a cross-sec- tional study approach, interest in sex was rela- tively stable among women of the same age in the two studies; whereas, significantly more men in 2005 than in 1995 reported an interest in sex (Lindau & Gavrilova, 2010). Rather than using a cross-sectional cohort study approach, changes or stability in sexual interest and enjoyment in aging individuals may also be studied by asking people how they perceive their current sexual interest and enjoyment compared to earlier in life. Such a retrospective approach has the advantage of studying change within individuals’ lifespan and may be complementary to cross-sectional approaches as previously used.

CONTACT Bente Traeen [email protected] Department of Psychology, University of Oslo, Box 1094 Blindern, Oslo, Norway. � 2019 Taylor & Francis Group, LLC

INTERNATIONAL JOURNAL OF SEXUAL HEALTH 2018, VOL. 30, NO. 4, 323–336 https://doi.org/10.1080/19317611.2018.1472704

Study aims

In a recent extensive review of the literature on sexuality after 60 years of age, Bell et al. (2017) concluded that there were methodological diffi- culties and significant inconsistencies in findings across studies. This pinpoints the need for studies that allow for cross-cultural comparison. Using common methods for data collection in represen- tative samples, the aim of this study is to test a conceptual model for change in sexual interest and sexual enjoyment compared to 10 years ago in older adults in Norway, Denmark, Belgium, and Portugal. This conceptual model is designed to study the degree to which structural factors (level of education), personal factors (sexual his- tory and general health), and interpersonal fac- tors (relationship characteristics) may predict the retrospectively-assessed dynamics of sexual inter- est and enjoyment. Because having a partner to have sex with is the strongest predictor of having sex and enjoying it (DeLamater, 2012; Palacios- Ce~na et al., 2012; Traeen et al., 2018), this study concentrated on older adults who have a partner.

Studying sexual interest and sexual enjoyment in older adults may have personal, social, and pub- lic health relevance, particularly regarding relation- ship happiness, well-being, and the perception of quality of life. The results from this study are likely to be of importance for public health professionals in planning and developing future interventions to improve sexual health in future generations of older adults (Traeen et al., 2016a,b).

The conceptual model

Structural factors

The relationship between socioeconomic status and health is well documented (Pampel, Krueger, & Denney, 2010). According to the European Commission (2016), the disposable median net income in 2015 was 8,435 EUR in Portugal, 21,654 EUR in Belgium, 28,364 EUR in Denmark, and 41,483 EUR in Norway. The dif- ferent socioeconomic realities are related to peo- ple’s standard of living, which may be why �Stulhofer et al. (2018) found that the average level of successful sexual aging was lowest in Portugal, but did not vary significantly between

Norway, Denmark, and Belgium. Many older adults are retired from paid work and live of their pension, which may make income a less meaningful predictor. On the other hand, educa- tion is usually correlated with income, which is why the level of education will be interpreted as a structural factor in this study.

Summing up the empirical evidence of factors associated with sexual expressions in partnered older adults, Kleinst€auber (2017) and Bell et al. (2017), found few studies examining the role of educational level and with conflicting results. However, the level of education may be of import- ance in deciding the position of sexuality in a per- son’s life, and thereby also on sexual interest as well as sexual enjoyment. Traditionally, highly educated people are more likely than people with less education to place a high value on sexuality (Schmidt, 1989; Traeen & Stigum, 1998). This cor- responds well with studies showing that older adults with higher levels of education have higher frequencies of sexual activity (Beckman, Waern, Gustafson, & Skoog, 2008; DeLamater & Sill, 2005; Palacios-Ce~na et al., 2012; Traeen et al., 2018), and greater physical pleasure (Stroope, McFarland, & Uecker, 2015). Studies have also found that level of education of older adults can serve as a protective factor against the diminishing of cognitive func- tion (Kok, Aartsen, Deeg, & Huisman, 2017). Furthermore, this should imply that the level of education would play a role with regard to sexual interest and sexual enjoyment in older adults. However, a recent study among older adults in Europe showed a significant, but small relationship between what was denoted as successful aging and tertiary education among only Norwegian women and Belgian men (�Stulhofer et al., 2018). This sug- gests that education does not play a crucial role in aging well in developed countries characterized by easily accessible health information and high qual- ity medical services.

Personal factors

As stated in the introduction, many studies show a negative link between sexual interest and age. Also, sexual satisfaction has been shown to be affected negatively by age. This strongly suggests that sta- bility and change in sexual interest and sexual

324 B. TRAEEN ET AL.

enjoyment may also be associated with age, which is why age is included in the conceptual model. However, age is also a possible covariate for the other factors, for instance health status.

Research suggests there are links between one’s own and one’s partner’s health problems and sexual activity (DeLamater, 2012; Dominguez & Barbagallo, 2016; Field et al., 2013; Lee et al., 2016; Lindau et al., 2007; Lindau, & Gavrilova, 2010; Palacios-Ce~na et al., 2012; Stroope et al., 2015; Syme, Klonoff, Macera, & Brodine, 2013). Accordingly, change in health status is likely to be associated with changes in sexual interest and sexual enjoyment. In this regard, it has been shown that people with poorer health are less likely to engage in sexual interaction (Lindau et al., 2007). Further, sexual interest and sexual enjoyment in older adults may be affected by physical disabilities, making some sexual positions uncomfortable or painful (Lindau & Gavrilova, 2010; Woloski-Wruble, Oliel, Leefsma, & Hochner-Celnikier, 2010).

Change in sexual interest and sexual enjoy- ment may also be affected by the aging individu- al’s level of sexual activity throughout his or her lifespan. It has been observed that individuals who were more sexually active at a younger age are more likely to continue being sexually active in older age (Kontula & Haavio-Mannila, 2009; Woloski-Wruble et al., 2010). This indicates that sexual interest and sexual enjoyment also should be relatively stable throughout a person’s lifespan.

Interpersonal factors

The number of years one has been in the couple relationship may affect their sexual interest and sexual enjoyment. Research suggests that sexual activity is negatively affected in a long-term rela- tionship by the degree of routine, lack of vari- ation, and boredom (DeLamater & Moorman, 2007; Kontula & Haavio-Mannila, 2009; Stroope et al., 2015). Sexuality within the couple relation- ship is shown to be dependent upon feeling close to, and intimate with, one’s partner (Avis et al., 2005; DeLamater, 2012; Galinsky & Waite, 2014; Stroope et al., 2015; Traeen, Stulhofer, & Carvalheira, 2013). According to Basson’s sexual desire model (2000, 2002), this is particularly so for women, as their motivation to move from

sexual neutrality to sexual arousal and potential desire and to continue the experience, stems from the need to enhance emotional closeness to the partner, acceptance, bonding, toleration, com- mitment, and love. In turn, this cyclic sexual response pattern is likely to lead to enhancement in sexual interest and sexual enjoyment. Furthermore, during aging there may be a shift of focus from vaginal penetration to other intim- ate sexual expressions such as touching, caressing, kissing, and cuddling, producing a sense of intimacy and closeness in the couple (Dominguez & Barbagallo, 2016). Resting on Bell et al. (2017) suggestion that sexual enjoyment may be concep- tualized differently in younger than in older indi- viduals, feeling emotionally close to one’s partner during sex, touching, and cuddling may be more important than traditional penetrative sex for older rather than for younger adults’ sexual inter- est and enjoyment. This could in fact increase sexual enjoyment in older individuals.

Method

Participants

The Department of Psychology at the University of Oslo, Norway, in cooperation with the market- ing research company IPSOS, conducted the multinational survey of representative samples of the population aged 60–75 years in Norway, Denmark, Belgium, and Portugal. Initially, IPSOS conducted a recruitment interview in each coun- try by telephone to obtain a nationally-represen- tative sample of this population. During this recruitment interview it was emphasized that the responses from those sexually inactive were as important as from those sexually active. As part of the study, a subsample of couples was recruited in each country. When recruiting indi- viduals, an effort was made to enlist both parties in a relationship if they were in the age range of 60–75 years.

Recruitment and procedure

The questionnaire was developed in English and subsequently translated into local languages by the principal investigators and persons employed by IPSOS in each country. Once the translation into

INTERNATIONAL JOURNAL OF SEXUAL HEALTH 325

native languages was finalized, randomized tele- phone recruitment of participants began. With the exception of Portugal, national phone registries (landline and mobile phone numbers) were used so that the sampling procedure would likely produce representative samples of the target population. In Portugal, a complete and updated telephone register did not exist. For this reason, IPSOS used a fre- quently used procedure when recruiting for tele- phone surveys in Portugal: (a) telephone numbers were first randomly selected from fixed phone directories and IPSOS’s own database of phone numbers; (b) to obtain a distribution representative of the population, participants were selected by age and gender; and (c) due to illiteracy problems, par- ticipants who had not completed primary school (ISCED 1) were excluded from the sample. For all countries telephone recruitment was carried out from October to December 2016. Ethics approval was handled by IPSOS in accordance with European standards. The ethical procedures fol- lowed the standards of ESOMAR (The European Society for Opinion and Market Research), as stated in the general contract with the University of Oslo. By the standards of ESOMAR, IPSOS is obliged to follow national and international rules and guide- lines for what is recognized as professionally sound market analysis. The rules comprise treatment of confidentiality, respondent anonymity, question- naires and databases and methods for data collec- tion etc. It is also referred to the ethical rules for The Norwegian Association of Marketing and Opinion Research. No compensation for participa- tion was given.

Informed consent was obtained from the par- ticipants when recruited received an anonymous, postal, questionnaire, including a Freepost enve- lope to return the completed questionnaire. Two reminders were sent successively, starting 1 week after the questionnaire was received by the par- ticipant. After a discussion with IPSOS in Portugal, it was decided to deliver the reminders by phone. Unfortunately, 502 potential Portuguese participants could not be reached. Of the 1,498 Portuguese individuals contacted by phone, 561 declined participation after having received the questionnaire. Overall, the response rates were 68% in Norway, 52% in Denmark, 57% in Belgium, and 26% in Portugal.

Survey questions

Most of the variables included in the question- naire were selected from previous studies among the target group. An overview of the included survey questions is given elsewhere (Traeen et al., 2018).

Measures

Outcome variables

Change in sexual interest and enjoyment was measured by two separate questions: “Compared to 10 years ago, how would you rate your overall enjoyment in sex?” and “Compared to 10 years ago, how would you rate your interest in sex?” The response categories for both questions ranged from 1 (much lower) to 5 (much higher).

Predictors

Age was measured as a continuous variable. Level of education was assessed as the highest level of formal education. In three countries the response categories ranged from 1 (primary school [6–8 years at school]) to 5 (higher university level [Master degree, Ph.D. level or similar]). In Belgium, additional response alternatives were added to mirror the educational system in the country. To allow for cross-cultural comparisons, the variable was recoded into 1 ¼ primary (1), 2 ¼ secondary (2 þ 3), and 3 ¼ tertiary educa- tion (4 þ 5).

Sexual activity throughout life was measured by the question: “In your lifetime, how would you rate your sexual activity throughout most of your life (until the age of 60)?” The response cat- egories ranged from 1 (I was sexually very active) to 5 (I was sexually very inactive).

General health status self-assessment was measured by the question “In general, would you say your health is … ” and the response catego- ries ranged from 1 (excellent) to 5 (poor).

Relationship duration was measured as a con- tinuous variable (in number of years) by the question: “If you have a steady/committed rela- tionship: How long have you been in this steady/ committed relationship?”

326 B. TRAEEN ET AL.

Emotional closeness during sex was measured by the question “Thinking about your relation- ship with your partner, how often does this apply to your situation: I feel emotionally close to my partner when we have sex together.” The response categories ranged from 1 (always) to 5 (hardly ever).

Statistical analysis

Based on census data, weighting was used to match national samples to their respective popu- lation characteristics (age and gender; DuMouchel & Duncan, 1983). To check for robustness, the analyses presented in this article were carried out on weighted and unweighted data. With the exception of some estimates in the Portuguese sample (presented in parenthesis in the results section), the estimates were similar.

The relationship between the outcome varia- bles and the selected predictors was studied using hierarchical linear regression analyses separately by country and gender (Pallant, 2010). First, the structural variable (level of education) was entered into the model, followed by personal fac- tors (age, sexual activity throughout life, health), and lastly, the interpersonal factors (duration of the relationship, emotional closeness with the partner during sex). Only the results from the final models are presented in Tables 3a to 4b. All data analyses were performed using IBM SPSS 22.0 statistical software package.

Results

Table 1 shows the rating of current sexual interest and sexual enjoyment compared to 10 years ago. Norwegian and Danish men tended to report their interest was the same or somewhat less than 10 years ago, and the majority of men in Belgium and Portugal reported less interest. Women’s esti- mates were generally lower than men’s estimates but showed the same pattern across countries.

Regarding the overall enjoyment of sex today compared to 10 years ago, a minority of men (4–7%) and women (4–10%) reported higher enjoyment. The percentage of women reporting less enjoyment ranged from 56% in Norway and Denmark, to 70% in Belgium, and 75% in Portugal. Most men in Portugal (73%), Belgium (64%), and Norway (53%) reported less enjoy- ment, and in Denmark (51%) claimed it was about the same.

Tables 2a and b show a description of the key variables presented in the conceptual model, by country and separate for men and women. The proportion of participants with tertiary education was lowest Portugal and highest in Norway.

Men and women in Denmark reported the longest relationship duration. The majority of men in all countries rated themselves as having been very to moderately sexually active through- out life. Danish and Norwegian men and women reported the greatest degree of emotional close- ness with their partner during sex, and men and women in Belgium the least closeness.

Table 1. Change in Sexual Interest and Overall Sexual Enjoyment Compared to 10 Years Ago in Men and Women from Norway, Denmark, Belgium, and Portugal (Percent, Weighted Data).

Men Women

Norway Denmark Belgium Portugal Sign Norway Denmark Belgium Portugal Sign

Sexual interest Much lower 13.5 13.6 31.0 20.4 ��� 25.1 23.2 46.2 32.8 ��� Somewhat lower 39.7 36.3 27.6 52.1 43.3 41.4 27.1 43.9 About the same 43.5 47.8 37.2 24.2 25.7 32.9 22.5 19.6 Somewhat higher 2.5 1.6 3.9 1.9 3.6 1.8 1.3 2.1 Much higher 0.8 0.7 0.3 1.4 2.3 0.7 3.0 1.6

(n ¼ 519) (n ¼ 433) (n ¼ 384) (n ¼ 211) (n ¼ 439) (n ¼ 435) (n ¼ 236) (n ¼ 186)

Sexual enjoyment Much lower 14.7 14.1 32.6 21.0 ��� 26.4 24.1 43.0 31.4 ��� Somewhat lower 38.6 30.5 31.6 51.8 29.9 32.1 27.1 43.4 About the same 40.2 51.3 27.9 22.1 33.9 38.1 22.2 21.4 Somewhat higher 4.8 3.8 6.6 2.6 7.8 3.6 4.1 1.9 Much higher 1.8 0.2 1.3 2.6 2.1 2.1 3.6 1.9

(n ¼ 505) (n ¼ 417) (n ¼ 377) (n ¼ 195) (n ¼ 425) (n ¼ 386) (n ¼ 221) (n ¼ 159) Note. ***p < 0.001.

INTERNATIONAL JOURNAL OF SEXUAL HEALTH 327

Ta b le

2a . A Pr es en ta ti on

of th e Pr ed ic to rs

U se d in

th e C on

ce p tu al M od

el in

Pa rt n er ed

M en

A cr os s Eu ro p ea n C ou

n tr ie s (M ,S D ); Pe rc en ta g es ).

V ar ia b le

N or w ay

(n ¼ 51 9)

D en m ar k (n ¼ 43 5)

Be lg iu m

(n ¼ 38 5)

Po rt ug

al (n ¼ 21 6)

n %

M SD

n %

M SD

n %

M SD

n %

M SD

Si g n .

A g e

(y ea rs )

51 9

66 .6 8

4. 34

43 7

67 .9 6

4. 27

38 4

67 .5 6

4. 11

21 5

66 .7 6

4. 38

�� �

D ur at io n of

th e re la ti on

sh ip

(y ea rs )

48 0

31 .2 4

16 .2 3

41 8

36 .8 3

14 .2 7

36 8

36 .5 7

14 .6 5

19 5

29 .7 3

17 .2 7

�� �

Se xu al

ac ti vi ty

th ro ug

h ou

t lif e

(h ig h er

va lu es

in d ic at e m or e in ac ti vi ty )

50 4

1. 81

0. 63

41 7

1. 89

0. 62

37 6

1. 95

0. 76

19 6

1. 76

0. 57

�� �

H ea lt h as se ss m en t (lo w er

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49 6

2. 58

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41 5

2. 43

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34 3

2. 72

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21 3

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0. 91

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49 6

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1. 71

0. 94

17 8

1. 63

1. 01

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9. 6

27 .4

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35 .6

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33 .1

37 .9

47 .5

47 .7

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57 .2

34 .7

41 .3

16 .7

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�� � p

< .0 01 .

Ta b le

2b . A Pr es en ta ti on

of th e Pr ed ic to rs U se d in

th e C on

ce p tu al

M od

el in

Pa rt n er ed

W om

en A cr os s Eu ro p ea n C ou

n tr ie s (m

ea n (M

), st an d ar d d ev ia ti on

(S D ); Pe rc en ta g es ).

N or w ay

D en m ar k

Be lg iu m

Po rt ug

al

V ar ia b le

n %

M SD

n %

M SD

n %

M SD

n %

M SD

Si g n .

A g e

(y ea rs )

44 0

66 .3 4

4. 05

44 0

67 .7 9

4. 25

23 6

65 .5 9

4. 05

20 3

66 .3 8

4. 36

�� �

D ur at io n of

th e re la ti on

sh ip

(y ea rs )

41 1

34 .9 1

16 .0 5

42 0

40 .3 2

13 .3 5

22 6

32 .5 0

16 .5 5

19 0

34 .1 4

17 .1 2

�� �

Se xu al

ac ti vi ty

th ro ug

h ou

t lif e (h ig h er

va lu es

in d ic at e m or e in ac ti vi ty )

43 0

2. 06

0. 71

38 8

2. 10

0. 67

22 4

2. 19

0. 81

16 1

1. 93

0. 73

��

H ea lt h as se ss m en t (lo w er

va lu es , b et te r h ea lt h )

40 5

2. 63

0. 95

38 8

2. 50

0. 94

21 6

2. 84

0. 86

19 8

3. 62

0. 83

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cl os en es s to

p ar tn er

d ur in g se x (lo w

va lu es

in d ic at e h ig h er

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41 1

1. 61

0. 86

35 9

1. 64

1. 03

21 7

1. 85

1. 06

15 2

1. 68

0. 92

�

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7. 8

25 .3

12 .9

44 .3

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42 .9

39 .3

54 .1

39 .8

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49 .3

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(n ¼ 43 8)

(n ¼ 43 8)

(n ¼ 23 3)

(n ¼ 20 1)

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� p < .0 5,

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< .0 01 .

328 B. TRAEEN ET AL.

A multivariate linear regression analysis was initially carried out on the polled sample, with countries as fixed effects. In the case of retro- spectively assessed change in sexual interest compared to 10 years ago, we found that Danish men differed from Belgian men. Among women, Belgian women significantly differed from women in the Portuguese, Norwegian, and Danish samples. Regarding change in sexual enjoyment in the past 10 years, the analysis showed that Norwegian and Danish men and women differed from Belgian men and women. As country was significant predictor of both outcomes, it was decided to run regression anal- yses by country to explore country-specific structure of predictors.

Change in sexual interest

Table 3a shows the relationship between the structural-, personal- and interpersonal factors and level of sexual interest today compared to 10 years ago in partnered men. With regard to the total explained variance of all the predictors included in the model, the proportion of explained variance in the outcome was 14.6% in Portugal, 10.9% in Norway, 9.0% in Belgium, and 6.0% in Denmark.

In the case of Portuguese men, the most signifi- cant predictors of level of sexual interest were sex- ual activity throughout life (weighted data b ¼ �0.21; unweighted data b ¼ �0.12), and rela- tionship duration (b ¼ 0.19). Health was not sig- nificant in the weighted data set (b ¼ �0.15) but reached significance in the unweighted data set (b ¼ �0.21). Portuguese men who had been in their relationship for a longer time and had been sexually active throughout their life were more likely to have unchanged or greater sexual interest compared to 10 years ago. In Norwegian men, the relative importance of the statistically significant predictors was health (b ¼ �0.20), duration of the relationship (b ¼ �0.14), and closeness with the partner during sex (b ¼ �0.10). This indicates that Norwegian men who were healthy, had been in the relationship for a shorter period, and per- ceived themselves as being close with their part- ner during sex were more likely to have unchanged or higher sexual interest compared to Ta b le

3a . Th e Re la ti on

sh ip

Be tw ee n Ra ti n g of

Pr es en t In te re st

in Se x C om

p ar ed

to 10

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an d a Se le ct ed

se t of

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in m en

A cr os s Eu ro p ea n C ou

n tr ie s (H ie ra rc h ic

M ul ti p le

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Re g re ss io n C oe ff ic ie n ts

fr om

th e Fi n al

St ep

of th e A n al ys is ).

Pr ed ic to r

N or w ay

(n ¼ 44 3)

D en m ar k (n ¼ 36 5)

Be lg iu m

(n ¼ 31 1)

Po rt ug

al (n ¼ 16 0)

b R2

D R2

b R2

D R2

b R2

D R2

b R2

D R2

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1: St ru ct ur al fa ct or s

0. 00 7

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s 0. 00 3

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< .0 01 .

INTERNATIONAL JOURNAL OF SEXUAL HEALTH 329

10 years ago. Turning to men in Belgium, the most important predictors were health (b ¼ �0.20), sex- ual activity throughout life (b ¼ �0.14), and age (b ¼ �0.12). Belgian men who had better health, who had been sexually active throughout life, and were younger, were more likely to have greater sexual interest now compared to 10 years ago. In Danish men, only health (b ¼ �0.20), was statistic- ally significantly associated with change in sexual interest. The personal factors made the largest con- tribution to the explained variance (DR2) for men in all countries.

The results for the analysis for women are pre- sented in Table 3b. The total explained variance of all the predictors included in the model was 18.3% in Portugal, 15.0% in Denmark, 11.6% in Norway, and 10.6% in Belgium.

In the case of Portuguese women, the most important predictors of change in sexual interest were health (weighted data b ¼ �0.237; unweighted data b ¼ �0.188), relationship dur- ation (b ¼ �0.17), and emotional closeness with the partner during sex (weighted data b ¼ �0.17; unweighted data b ¼ �0.32). Portuguese women who were in good health, felt emotionally close to their partner during sex, had been in the rela- tionship for a shorter period of time, and were more likely to have unchanged or greater sexual interest compared to 10 years ago. The personal factors made the largest contribution to the explained variance in Portuguese women. In Danish women, perceived intimacy with the part- ner during sex (b ¼ �0.31), and health evaluation (b ¼ �0.15) were statistically significantly associ- ated with change in sexual interest. Danish women who had good health and perceived themselves as close to their partner were more likely to have unchanged or greater sexual inter- est compared to 10 years ago.

Turning to women in Norway, the most signifi- cant predictors were emotional closeness with the partner (b ¼ �0.27), and duration of the relation- ship (b ¼ �0.14). Norwegian women who felt close to their partner during sex and had been in the relationship for a shorter period of time were more likely to have unchanged or greater sexual interest compared to 10 years ago. In Belgium, emotional closeness with the partner during sex (b ¼ �0.22), and relationship duration (b ¼ �0.15)

were statistically significantly associated with change in sexual interest. Women who perceived themselves as close to their partner during sex and had been in the relationship for a shorter period of time had unchanged or greater sexual interest compared to 10 years ago. In Norway, Denmark, and Belgium, the interpersonal factors made the largest contribution to the explained variance in women.

Change in sexual enjoyment

Table 4a shows the relationship between the pre- dictor variables and overall level of sexual enjoy- ment in partnered men today compared to 10 years ago. The proportion of total variance explained in the outcome, based on all of the predictors included in the men’s models, was 18.2% in Portuguese men, 12.4% in Belgian men, 11.0% in Norwegian men, and 10.8% in Danish men.

The relative importance of the statistically sig- nificant predictors in Portuguese men, were emo- tional closeness (weighted data b ¼ �0.20; unweighted data b ¼ �0.13), previous sexual activity (weighted data b ¼ �0.18; unweighted data b ¼ �0.10), and health (weighted data b ¼ �0.17; unweighted data b ¼ �0.26). Portuguese men who had good health, felt close to their partner, and had been sexually active throughout their life were more likely to have unchanged or greater sexual enjoyment when compared to 10 years ago. In Belgian men, health (b ¼ �0.28), and duration of the relationship (b ¼ �0.16) predicted sexual enjoyment. Belgian men who had better health, and who had been with their partner for a shorter length of time were more likely to have unchanged or greater overall sexual enjoyment when compared to 10 years ago. Turning to Norwegian men, the most significant predictors of enjoyment were health (b ¼ �0.20), emotional closeness (b ¼ �0.14), and relationship duration (b ¼ �0.13). Norwegian men who were in good health, felt close to their partner during sex, and who had been in the relationship for a shorter time, were more likely to report unchanged or greater overall sexual enjoyment compared to 10 years ago. The most important predictors in Danish men were health

330 B. TRAEEN ET AL.

Ta b le

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of th e A n al ys is ).

Pr ed ic to r

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(n ¼ 35 5)

D en m ar k (n ¼ 31 5)

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(n ¼ 18 6)

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D R2

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INTERNATIONAL JOURNAL OF SEXUAL HEALTH 331

(b ¼ �0.26), emotional closeness (b ¼ �0.14), and previous sexual activity (b ¼ �0.10). Danish men who had good health, who felt close to their partner, and had been sexually active throughout life, were more likely to have unchanged or greater overall sexual enjoyment compared to 10 years ago. The personal factors made the larg- est contribution to the explained variance in men in all countries. The total variance explained of all the predictors included in the women’s models was 19.3% in Belgium, 16.0% in Denmark, 15.2% in Portugal, and 14.3% in Norway (Table 4b).

In Belgium, health (b ¼ �0.27), emotional closeness (b ¼ �0.22), and duration of the rela- tionship (b ¼ �0.16) were statistically signifi- cantly associated with overall sexual enjoyment today compared to 10 years ago. Women who were in good health, felt emotionally close to their partner, and who had been in the relation- ship for a shorter period reported unchanged or greater overall sexual enjoyment. The relative importance of the statistically significant predic- tors of Danish women were intimacy with the partner (b ¼ �0.35), and health (b ¼ �0.15). Likewise, the most significant predictors of Portuguese women were emotional closeness (weighted data b ¼ �0.25; unweighted data b ¼ �0.27), and health (weighted data b ¼ �0.22; unweighted data b ¼ �0.19). Danish and Portuguese women who were emotionally close with their partner, and in good health were more likely to report unchanged or greater overall sex- ual enjoyment compared to 10 years ago. Turning to women in Norway, the most import- ant predictors of change in sexual enjoyment were intimacy (b ¼ �0.32), and duration of the relationship (b ¼ �0.16). Norwegian women who had been in the relationship for a shorter period, and felt emotionally close to their partner during sex, were more likely to have unchanged or greater overall sexual enjoyment today compared to 10 years ago.

In the analyses of the Norwegian, Danish and Belgian women, the interpersonal factors made the largest contribution to the explained variance while in the case of the Portuguese women, the personal factors made the largest contribution. Ta

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Pr ed ic to r

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(n ¼ 35 1)

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332 B. TRAEEN ET AL.

Discussion

Using a conceptual model to inform and orien- tate the exploration, the aim of this study was to investigate the change in sexual interest and sex- ual enjoyment in partnered older adults today compared to 10 years ago in Norway, Denmark, Belgium, and Portugal. We found that across countries, personal factors were most important for predicting sexual interest and sexual enjoy- ment in men; health most often being the most significant predictor. In Norwegian, Danish, and Belgian women, interpersonal factors were most important for predicting sexual interest and sex- ual enjoyment compared to 10 years ago. Personal factors were most important for Portuguese women in this respect.

We found that in all countries, except Portugal, men’s evaluation of their own health was important for current sexual interest. Health was also of significance to women’s change in sexual interest in Denmark and Portugal. Health was of importance to overall sexual enjoyment for men and women in all countries, with the exception of Norwegian women. That health is important for sexual interest and enjoyment sup- ports previous research which has shown that there is a relationship between reduced health and diminished interest in sex, as well as fre- quency of sexual activity (DeLamater, 2012; Field et al., 2013; Lee et al., 2016; Lindau & Gavrilova, 2010; Lindau et al., 2007; Palacios-Ce~na et al., 2012; Stroope et al., 2015; Syme et al., 2013).

Previous sexual activity in life was of import- ance for current sexual interest in Portuguese and Belgic men, and for current sexual enjoy- ment in Danish and Portuguese men. However, previous activity did not predict sexual interest and enjoyment in women. Men who had been sexually active throughout their life were more likely to have unchanged or higher sexual interest and enjoyment compared to 10 years ago. These findings support Kontula’s and Haavio-Mannila’s (2009) study, which found that Finnish men who had been more sexually active at a younger age were more likely to continue being sexual active in older age. This could point to a gender differ- ence in sex drive (Baumeister, Catanese, & Vohs, 2001), or what Baumeister (2000) denotes as

erotic plasticity, and that men’s sexual drive as well as sexual habits are more stable across the lifespan, whereas women’s sexuality is more plas- tic and dependent on social and cultural factors.

With the exception of Belgian men and Danish men and women, duration of the relationship was a significant predictor of sexual interest today com- pared to 10 years ago. Likewise, duration of the rela- tionship predicted overall sexual enjoyment in Belgian and Norwegian men and women but not Danish and Portuguese men and women. Those who had been in their relationship for a shorter length of time were more likely to report unchanged or greater sexual interest and enjoyment. These findings sup- port previous studies which have shown that habitua- lization of the sex life may occur in long-term relationships (DeLamater & Moorman, 2007; Kontula & Haavio-Mannila, 2009; Stroope et al., 2015), and, as a result, both sexual interest and enjoy- ment may be reduced. On the other hand, the sexual frequency is probably higher in couple relationships that have lasted for a shorter period of time (Stroope et al., 2015), and where the partners are new to each other both physically and emotionally.

Except for Norwegian men, perceived emo- tional closeness with the partner during sex did not predict sexual interest in men but in women in all countries. On the other hand, emotional closeness was a powerful predictor of current sex- ual enjoyment in all respondents except men in Belgium. These findings are consistent with pre- vious research (Avis et al., 2005; Call, Sprecher, & Schwartz, 1995; DeLamater, 2012; Galinsky & Waite, 2014; MacNeil & Byers, 2005; Sprecher, 2002; Stroope et al., 2015; Traeen et al., 2013). The findings not only support Basson’s (2000, 2002) hypothesis of women’s sexual desire cycles, but extends this cycle to be valid also for aging men. Thus, a perception of closeness with the partner during sex is associated with unchanged sexual interest in aging women, and with enhanced sexual enjoyment in both aging men and women across cultures. When sexual enjoy- ment and emotional closeness are linked for both women and men, this could indicate that sexual enjoyment in aging men is being more connected to emotional factors than earlier in a man’s life.

The largest contribution to the variance explained in all of men’s current sexual interest

INTERNATIONAL JOURNAL OF SEXUAL HEALTH 333

and sexual enjoyment was from personal factors with health and sexual activity throughout life being the most important predictors. For Norwegian, Danish, and Belgian women’s current sexual interest and sexual enjoyment, interper- sonal factors were the most important; whereas, personal factors were most important to Portuguese women. This indicates a clear gender difference, even more than cross-cultural differ- ences, in what stabilizes sexual interest and enjoyment over the lifespan. Men’s sexual interest and enjoyment may be more dependent on the biological aspects of the body, and women’s sex- ual interest and enjoyment may be more depend- ent on the psychological aspects of their relationships.

Education predicted neither change in sexual interest nor change in overall sexual enjoyment. Since this result is derived from studies that allow for cross-cultural comparisons, it is likely that in older age the impact of education becomes less sig- nificant compared to other factors that influence sex- ual interest and sexual enjoyment. The same might be true for age. Age predicted current sexual interest in only Norwegian and Belgian men, and the direc- tion of the relationship was expected as previous research has shown that sexual activity decreases with increasing age (DeLamater, 2012; Traeen et al., 2017). However, age was not a significant predictor of change in sexual enjoyment in men and women in the other countries. This indicates that changes may occur at a later stage of life, or that once the other predictors have been controlled for, age is no longer important by itself. Of particular importance in this respect may be aspects of physical health (Bell et al., 2017; Wang et al., 2015).

The strengths of this research are consistent research design and method of data collection across all four countries, the sample sizes, and the use of mainly validated measures. However, the present study has some limitations that need to be addressed. There is reason to believe that the sam- ples are somewhat biased towards older adults who were sex-positive. Furthermore, the findings are relevant exclusively for heterosexual individuals, because only 1.9% of the recruited participants identified as gay, lesbian, or bisexual, and 3.2% marked “other”. Another limitation was that while the participants had agreed to complete the survey,

they may have experienced embarrassment in responding to the questions about intimate details of their sex life. Lastly, change in sexual interest and sexual enjoyment in the past 10 years were measured retrospectively. This means that the par- ticipant had to remember his or her level of inter- est/enjoyment 10 years ago. Taking into account the findings suggesting that up to 20% of critical details of a recognized event are irretrievable after 1 year and 50% after 5 years (Hassan, 2005), the precision of our measure is problematic. However, there is no reason to assume any systematic differ- ences in memory bias above and beyond age differ- ences (which were controlled for in the multivariate models).

Conclusions and implications

Of importance to maintaining sexual interest and enjoyment in partnered older adults across Europe is good health, an active sex life through- out the lifespan, duration of the relationship, and feeling emotionally close to their partner during sex. There is evidence that health professionals tend to exclude sexual health as a topic in meet- ing with older adults (Hinchliff & Gott, 2011; Traeen & Schaller, 2013). However, this study shows that sexual health is an important issue to address as part of older adults’ well-being and, therefore, an important issue to raise in meetings with older adult patients, particularly the psycho- logical and relational aspects of sexuality. To achieve this goal, it is essential that sexual health becomes an integral part of the curriculum in the training of health professionals, and that policy makers acknowledge sexuality as a priority area in planning for health services.

Funding

This project was supported by The Norwegian Research Council (Grant Number 250637).

References

Avis, N. E., Zhao, X., Johannes, C. B., Ory, M., Brockwell, S., & Greendale, G. A. (2005). Correlates of sexual function among multi-ethnic middle-aged women: Results from the study of women’s health across the nation (swan).

334 B. TRAEEN ET AL.

Menopause: The Journal of The North American Menopause Society, 12(4), 385–398.

Basson, R. (2000). The female sexual response: A different model. Journal of Sex and Marital Therapy, 26(1), 51–65. doi:10.1080/009262300278641

Basson, R. (2002). A model of women’s sexual arousal. Journal of Sex and Marital Therapy, 28(1), 1–10. https:// doi.org/10.1080/009262302317250963

Baumeister, R. F. (2000). Gender differences in erotic plasti- city: The female sex drive as socially flexible and respon- sive. Psychological Bulletin, 126(3), 347–374.

Baumeister, R. F., Catanese, K. R., & Vohs, K. D. (2001). Is there a gender difference in strength of sex drive? Theoretical views, conceptual distinctions, and a review of relevant evidence. Personality and Social Psychology Reviews, 5(3), 242–273.

Beckman, N., Waern, M., Gustafson, D., & Skoog, I. (2008). Secular trends in self reported sexual activity and satisfac- tion in Swedish 70 year olds: Cross sectional survey of four populations, 1971–2001. BMJ, 337(7662), a279. doi:10.1136/bmj.a279

Bell, S., Reissing, E. D., Henry, L. A., & VanZuylen, H. (2017). Sexual activity after 60: A systematic review of associated factors. Sexual Medicine Reviews, 5(1), 52–80. doi:10.1016/j.sxmr.2016.03.001

Call, V., Sprecher, S., & Schwartz, P. (1995). The incidence and frequency of marital sex in a national sample. Journal of Marriage and the Family, 57, 639–652.

DeLamater, D. J., & Sill, M. (2005). Sexual desire in later life. The Journal of Sex Research, 42(2), 138–149.

DeLamater, J., & Moorman, S. M. (2007). Sexual behavior in later life. Journal of Aging and Health, 19(6), 921–945.

DeLamater, J. (2012). Sexual expression in later life: A review and Synthesis. The Journal of Sex Research, 49(2-3), 125–141.

DuMouchel, W. H., & Duncan, G. J. (1983). Using sample survey weights in multiple regression analyses of stratified samples. Journal of the American Statistical Association, 78(383), 535–543.

Dominguez, L. J., & Barbagallo, M. (2016). Ageing and sexuality. European Geriatric Medicine, 7(6), 512–518. Retrieved from http://dx.doi.org/10.1016/j.eurger.2016.05. 013

European Commission. (2016). Median income – Eurostat. Retrieved September 26, 2017, from http://ec.europa.eu/ eurostat/web/gdp-and-beyond/quality-of-life/median-income

Field, N., Mercer, C. H., Sonnenberg, P., Tanton, C., Clifton, S., Mitchell, K. R., … , Johnson, A. M. (2013). Associations between health and sexual lifestyles in Britain: Findings from the third national survey of sexual attitudes and lifestyles (Natsal-3). The Lancet, 382(9907), 1830–1844. doi:10.1016/S0140-6736(13)62222-9

Galinsky, A. M., & Waite, L. J. (2014). Sexual activity and psychological health as mediators of the relationship between physical health and marital Quality. The Journals of Gerontology: Series B, 69(3), 482–492. Retrieved from https://doi.org/10.1093/geronb/gbt165

Hassan, E. (2005). Recall bias can be a threat to retrospect- ive and prospective research designs. The Internet Journal of Epidemiology, 3(2), 1–7. http://ispub.com/IJE/3/2/ 13060

Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, D. (2010). Sexual behavior in the United States: Results from a national probability sample of men and women ages 14–94. The Journal of Sexual Medicine, 7(5), 255–265.

Hinchliff, S., & Gott, M. (2011). Seeking medical help for sexual concerns in mid- and later life: A review of the lit- erature. Journal of Sex Research, 48, 106–117.

Kleinst€auber, M. (2017). Factors associated with sexual health and well-being in older adulthood. Current Opinion in Psychiatry, 30(5), 358–368. doi:10.1097/ YCO.0000000000000354

Kok, A. A., Aartsen, M. J., Deeg, D. J., & Huisman, M. (2017). Capturing the diversity of successful aging: An operational definition based on 16-year trajectories of functioning. Gerontologist, 57(2), 240–251.

Kontula, O., & Haavio-Mannila, E. (2009). The impact of aging on human sexual activity and sexual desire. The Journal of Sex Research, 46(1), 46–56.

Laumann, E. O., Gagnon, J. H., Michaels, R. T., & Michaels, S. (1994). The social organization of sexuality: Sexual practices in the United States. Chicago: University of Chicago Press.

Lee, D. M., Nazroo, J., O’Connor, D. B., Blake, M., & Pendleton, N. (2016). Sexual health and well-being among older men and women in England: Findings from the English longitudinal study of ageing. Archives of Sexual Behavior, 45(1), 133–144.

Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., O’Muircheartaigh, C. A., & Waite, L. J. (2007). A study of sexuality and health among older adults in the United States. The New England Journal of Medicine, 357(8), 762–774.

Lindau, S. T., & Gavrilova, N. (2010). Sex, health, and years of sexually active life gained due to good health: Evidence from two US population based cross sectional surveys of ageing. British Medical Journal, 340(c810), 1–11.

MacNeil, S., & Byers, E. S. (2005). Dyadic assessment of sexual self-disclosure and sexual satisfaction in heterosex- ual dating couples. Journal of Social and Personal Relationships, 22(2), 169–181. Retrieved from http://psy- cnet.apa.org/doi/10.1177/0265407505050942

Palacios-Ce~na, D., Carrasco-Garrido, P., Hern�andez-Barrera, V., Alonso-Blanco, C., Jim�enez-Garc�ıa, R., & Fern�andez- de-las-Pe~nas, C. (2012). Sexual behaviors among older adults in Spain: Results from a population-based national sexual health survey. The Journal of Sexual Medicine, 9(1), 121–129. doi:10.1111/j.1743-6109.2011.02511.x

Pallant, J. (2010). SPSS survival manual: A step by step guide to analysis using SPSS (4th ed.). Maidenhead: McGraw-Hill.

Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010). Socioeconomic disparities in health behaviors. Annual

INTERNATIONAL JOURNAL OF SEXUAL HEALTH 335

Review of Sociology, 36, 349–370. Retrieved from http:// doi.org/10.1146/annurev.soc.012809.102529

Schick, V., Herbenick, D., Reece, M., Sanders, S. A., Dodge, B., Middlestadt, S. E., & Fortenberry, J. D. (2010). Sexual behaviors, condom use, and sexual health of Americans over 50: Implications for sexual health promotion for older adults. The Journal of Sexual Medicine, 7(1), 315–329.

Schmidt, G. (1989). Sexual permissiveness in Western soci- eties. Roots and course of development. Nordisk Sexologi, 7(4), 225–234.

Sprecher, S. (2002). Sexual satisfaction in premarital rela- tionships: Associations with satisfaction, love, commit- ment, and stability. Journal of Sex Research, 39(3), 190–196. doi:10.1080/00224490209552141

Stroope, S., McFarland, M. J., & Uecker, J. E. (2015). Marital characteristics and the sexual relationships of U.S. older adults: An analysis of national social life, health, and aging project data. Archives of Sexual Behavior, 44(1), 233–247.

�Stulhofer, A., Hinchliff, S., Jurin, T., Hald, G. M., & Traeen, B. (2018). Successful aging and the dynamics of sexual interest and enjoyment in aging European men and women. The Journal of Sexual Medicine, 15, 1393–1402. https://doi.org/10.1016/j.jsxm.2018.08.011

Syme, M. L., Klonoff, E. A., Macera, C. A., & Brodine, S. K. (2013). Predicting sexual decline and dissatisfaction among older adults: The role of partnered and individual physical and mental health factors. Journals of Gerontology. Series B: Psychological Sciences and Social Sciences, 68(3), 323–332.

Traeen, B., & Stigum, H. (1998). Parallel sexual relationships in the Norwegian context. Journal of Community & Applied Social Psychology, 8(1), 41–56. doi:10.1002/ (SICI)1099-1298(199801/02)8:13.0.CO;2-3

Traeen, B., Stulhofer, A., & Carvalheira, A. (2013). Satisfaction with the division of housework, partner’s perceived attractiveness, emotional intimacy, and sexual satisfaction in married or cohabiting Norwegian middle- class men. Sexual and Relationship Therapy, 28(3), 215–229.

Traeen, B., & Schaller, S. (2013). Talking to patients about sexual issues: Experiences of Norwegian psychologists. Sexual and Relationship Therapy, 28(3), 283–293.

Traeen, B., Hald, G. M., Graham, C., Enzlin, P., Janssen, E., Kvalem, I. L., … �Stulhofer, A. (2016a). An overview of the literature on sexuality in older adults (65þ), part 1: Sexual Function and its difficulties. International Journal of Sexual Health, 29(1), 1–10.

Traeen, B., Carvalheira, A. A., Kvalem, I. L., �Stulhofer, A., Janssen, E., Graham, C., … Enzlin, P. (2016b). An overview of the literature on sexuality in older adults (65þ), part 2: Body image and sexual satisfaction. International Journal of Sexual Health, 29(1), 11–21.

Træen, B., �Stulhofer, A., Janssen, E., Carvalheira, A. A., Hald, G. M., Lange, T., & Graham, C. (2018). Sexual activity and sexual satisfaction among older adults in four European countries. Archives of Sexual Behavior. doi:10.1007/s10508-018-1256-x.

Wang, V., Depp, C. A., Ceglowski, J., Thompson, W. K., Rock, D., & Jeste, D. V. (2015). Sexual health and function in later life: A population-based study of 606 older adults with a partner. American Journal of Geriatric Psychiatry, 23(3), 227–233. http://dx.doi.org/10.1016/j.jagp.2014.03. 006.

Woloski-Wruble, A. C., Oliel, Y., Leefsma, M., & Hochner- Celnikier, D. (2010). Sexual activities, sexual and life sat- isfaction, and successful aging in women. The Journal of Sexual Medicine, 7(7), 2401–2410.

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