Gender Differences in Sexuality in different Cultures

10.1177/0022167804264106THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES / April 2004Sharpe / INTRODUCTION TO SEXUALITY IN LATE LIFE

❖ Sex Therapy

Introduction to Sexuality in Late Life

Thomasina H. Sharpe University of South Alabama

Sexuality is an aspect of human development often ignored at vari- ous stages of life, especially late life. With the aging of society, in- creased longevity, improved health, and rising affluence, the understanding of normal sexual development in aging humans be- comes progressively more important. Normal sexuality among those in late life may relate more to societal views based in part on ageist myths and misconceptions and an overemphasis on disease pro- cesses. It is important for both health and mental health profession- als to educate themselves about the specific challenges and rewards of sexuality in late life.

Keywords: elder sexuality; late-life sexuality; geriatric; sexual development

Sexuality in late life is big news. A lead article in AARP theMagazine recently announced that “60 Is the New 30!” with a steamy picture of a graying supermodel on its cover (Sherrill, 2003). The best-selling memoir A Round-Heeled Woman: My Late-Life Adventures in Sex and Romance (Juska, 2003) follows the sexual exploits of a woman who places a personal ad in the New York Times that reads, “Before I turn 67 next March I want to have a lot of sex with men I like.” Wall Street has finally figured out that sex sells to aging baby boomers, who are living longer, healthier, and wealthier lives than their parents (Katz & Marshall, 2003). In addition, newspapers (e.g., Leary’s, 1998, article in the New York Times) print survey results from organizations such as the National Council on the Aging (1998) showing that people are maintaining satisfying sex lives well into their 80s and even 90s. Yet for all its newfound attention, little is actually known about sexuality in late life.

It is important to acknowledge that late life is a sexual stage of development like any other across the life span. Sexu- ality, often used as a general term for the feelings and behav- iors of a human being concerning sex, encompasses both sex- ual behaviors and sexual desire (Carroll & Wolpe, 1996). Each stage of sexual development has its own tasks and out- comes. Levy (1994) pointed out that sexuality is defined as an erotic psychosocial response that can be expressed alone or with others through a variety of sexual acts that may differ in type and frequency as a person grows older. For example, sex- uality and sexual behavior in very young children is based mainly on curiosity. In adolescence, sexual development begins to provide a sense of identity, an opportunity to experi- ence emotional intimacy, the freedom to explore and become comfortable with one’s own body, and the chance to master skills useful in the transition into adulthood. Young adults’ sexual development encompasses the passage from depend- ence to independence and then to sexual bonding and cou- pling. Sexual behavior among young adults serves purposes of procreation and the solidification of pair bonds. This changes in midlife as sexual development shifts its primary goal from procreation to pleasure. Sexual activity in older individuals usually continues to be a satisfying sexual expres- sion and is related even more directly to the motivation, needs, and satisfaction of the participants (Hillman, 2000; Stone, Wyman, & Salisbury, 1999).

Sexual development is an understudied area of research at all ages, and little is known about what is normal sexual development in late life. There are many reasons for this lack of knowledge. First, there is a difference between normal and average sexual development. So little about late life sexuality has been studied that researchers often base assertions on sur- veys that blur the differences between what is normal and what is average. For example, a study by the Association of Reproductive Health Professionals (2002) reported that 52% of men 50 to 59 years of age, 26% of men 60 to 69 years of age, and 27% of men 70 years of age and older engaged in sexual activity more than once a week. This may give researchers a benchmark for which to aim and make an excel- lent sound bite, but it reveals little about whether this is nor-

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THE FAMILY JOURNAL: COUNSELING AND THERAPY FOR COUPLES AND FAMILIES, Vol. 12 No. 2, April 2004 199-205 DOI: 10.1177/0022167804264106 © 2004 Sage Publications

Correspondence concerning this article should be addressed to Thomasina H. Sharpe, M.D., University of South Alabama, 307 Uni- versity Boulevard, HSB, Suite 1450, Mobile, AL 36688-0002; e- mail: [email protected]. Sex Therapy Column Editor’s Note: This article is the final of a three-part series written by Dr. Sharpe that addresses human sexual development. Dr. Sharpe’s family medicine perspective encourages a holistic approach to sexuality, aging, and family therapy.

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mal sexual development in this age group. Taken alone, it may confuse individuals and, specifically, health and mental health professionals into believing that this is a goal that must be met or exceeded to demonstrate healthy aging.

Second, the literature sometimes fails to provide a com- prehensive picture of those in late life, often concentrating more on dysfunction or disease than on healthy sexual devel- opment. In addition, most of the literature on sexuality in the aged is based on what Railene Shippie-Rice calls “The Clas- sic Triad” in her chapter that appears in Sexual Health Promo- tion (Fogal & Lauver, 1990). The Triad to which she refers is composed of the seminal work of Kinsey, Pomeroy, and Mar- tin (1948a, 1948b); the evaluations of the Duke Longitudinal Studies by Pfeiffer,Verwoerdt, and Wang (1968) as well as Pfeiffer and Davis (1972); and research by Masters and John- son (1966). Kinsey et al.’s investigations into sexual behavior shattered many commonly held myths about sexual activities practiced by elderly men and women. The pioneering research of Masters and Johnson formed the basis of most sexual teaching on the normal physiology of aging. Likewise, the Duke Longitudinal Studies work represented strong sci- entific inquiry into the sexual behavior of older individuals.

Although the classic triad opened discussion of sexuality and its development, the research was flawed in its wide- spread application to the elderly. Examination reveals that older persons largely were ignored as a sample or subject of analysis in all of these studies. For example, older people were administered only a portion of the total instrument dur- ing the classic studies of Kinsey et al. (1948a, 1948b) and were excluded completely toward the end of the fieldwork. The findings of their work and those of and Masters and John- son (1966) were hindered by their small survey sizes. Masters and Johnson observed only 31 men and women over age 60, and only 9 were over 70 years old. Caution must be used when applying the findings of such small samples to the general population of the elderly.

Similarly, the cultural and social changes that have occurred over the past 20 to 50 years, as well as improvements in health and advanced longevity, challenge the relevance of these studies to today’s elderly. For example, because the average woman lives to age 82 and thus can be expected to live one third of her life after menopause, a fourth of her sexu- ality will be experienced in late life (Kingsberg, 2002). It is amazing that so little is known about the normal sexual devel- opment of this group and that what is taught to health care providers is based on such small groups of individuals studied over half a century ago.

The third reason little is known about this stage is that the elderly are a more heterogeneous group than most people believe. The definition of an aged individual continues to change as medical advances improve the quality and quantity of our lives. The definition of late life tends to include those persons over the age of 65, the most common time of retire-

ment and the onset of Social Security and Medicare benefits. Yet the growing numbers of 70-, 80-, and even 90-year-olds in our population makes this a life stage that may span greater than 30 years. The sexual development and challenges of a 65-year-old executive and a 98-year-old institutionalized Alzheimer’s patient are not unlike the differences between a 15-year-old student and his 43-year-old mother. In fact, by this definition, multiple generations of one family may fall into the sexual category of “aged.”

When discussing late life, it is important to determine what is “old.” Someone who is in his or her 80s may not consider himself or herself “old.” Aging can be defined objectively as a universal process that begins at birth; but subjectively, aging is associated with chronological age or older adults (Schuster & Ashburn, 1992). For the purposes of this article, I propose the subjective definition of aging and late life to be from age 65 until death.

Herein, I speak broadly of what is known of the normal development and specific problems of sexuality in late life and follow with special populations and specific problems of sexuality for older adults. I also explore some of what is known about this rapidly growing and fascinating time of life.

THEORIES OF DEVELOPMENT AND AGING

Sexuality in late life is a culmination of all of the develop- mental processes an individual has experienced thus far. This stage is marked by a stable sense of self-identity. Most changes take place subtly, even in reference to great life- changing events. Most individuals continue to see themselves as basically the same persons they have always been (Schuster & Ashburn, 1992).

Cummings and Henry (1961) first described the Disen- gagement Theory. They maintained that in old age, individu- als and society mutually withdraw from each other in four steps. The first begins in late middle age, when traditional roles, such as worker and parent, become less available or less important, and one’s social circle shrinks because friends die or move away. Second, people anticipate, adjust to, and par- ticipate in this narrowing of the social sphere by giving up many of the roles they have played and accepting this disen- gagement. Third, as people become less role centered, their styles of interaction change from active to passive. Last, because of these more passive styles of interaction, older peo- ple are less likely to be chosen for new roles and therefore are likely to disengage more.

The Disengagement Theory proposes that the elderly’s participation in the disengagement process is universal and voluntary (Cummings & Henry, 1961). The most unfortunate aspect of this theory is that it reinforces many ageist stereo- types. Palmore (1999) found that it perpetuated discrimina- tion, including everything from forced retirement to socially sterile nursing homes, on the grounds that the elderly, after all, want to withdraw.

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An opposing theory is the Activity Theory, which pro- poses that older people age most successfully when they par- ticipate in a full round of daily activities, that is, keep busy (Lemon, Bengtson, & Peterson, 1972). According to this the- ory, the more active one is and the more roles one plays, the greater one’s life satisfaction and the longer one’s life. Many of the elderly believe that activity is the key to successful aging, so much so that gerontologists have dubbed this phi- losophy “the busy ethic” (Ekerdt, 1986).

It seems that the best sign of satisfaction is not the absolute number of roles or activities but how close the level of activity is to the level an individual desires (Lomranz, Bergman, & Shmotkin, 1988). This is the general basis of the Continuity Theory, which states that each person deals with late adult- hood in much the same way that he or she coped with earlier periods of life (Atchley, 1989). Erikson (1984) explained late life as a time for reflecting on one’s own life and life roles. He described the developmental task of old age in terms of ego integrity and ego despair. Ego integrity is seen as acceptance of the way one has lived and is still living one’s life. It is also the evaluation that one was and still is in control of life. Erikson defined the failure to master this stage as ego despair. Ego despair is a state of conflict about the way one has lived and continues to live one’s life. It is the subjective experience of dissatisfaction, disappointment, or disgust about the course of one’s life, together with the conviction that if given another chance, one would live life differently. Such individ- uals despair and therefore fear death (Schuster & Ashburn, 1992).

The two theories seem most true of an individual’s sexual- ity. If a person has successfully developed a sense of ego integrity, then he or she is more likely to accept sexuality and continue to feel in control. A sense of satisfaction in one’s past sexual experience is the best predictor of a person’s satis- faction with sexuality in late life. Sexual activity decreases as one ages, but sexual satisfaction does not (Schuster & Ashburn, 1992). In fact, seniors find that sex does not decrease as much as it evolves. Physiologically, humans can- not avoid the march of time. Bodies change, and although what is considered normal aging is based on a very small sur- vey of individuals conducted more than 30 years ago, changes do occur. Older individuals also find that they are not immune to the effects of societal and peer attitudes on what is consid- ered acceptable behavior. Physiological and societal effects are important influencing forces on sexuality in late life.

SEXUAL PHYSIOLOGY IN LATE LIFE

Most articles and texts adhere closely to the observations of Masters and Johnson (1966). They concentrate on senes- cence, or the weakening and decline of the body, as well as the sexual response cycle and the changes found in individuals over the age of 40. The sexual response cycle consists of four

phases: drive (desire), arousal, release (orgasm), and resolu- tion (the refractory period). In both men and women, drive or desire remains stable throughout life or at least into the ninth decade. Multiple studies have demonstrated that the fre- quency of activity may decrease, but desire appears constant (Avis, 2000; Kingsberg, 2002; Laumann, Paik, & Rosen, 1999; Schuster & Ashburn, 1992).

Arousal is the phase most affected by aging. In women, the decline and eventual cessation of estrogen production during menopause may lead to the atrophy of urogenital tissues and an overall decrease in genital vasocongestion and lubrication during arousal. Both sexes may experience prolonged arousal phases, which may require more direct genital stimulation (Demeter, 1998; Masters & Johnson, 1966; Miller, Versi, & Renik, 1999).

Orgasm (the resolution phase) tends to be the phase least affected by aging. Men may need sustained direct stimulation and take more time for orgasm to occur. They may have decreased volume of ejaculate and less forceful ejaculation. Women who are multiorgasmic will remain so in late life. Some women may experience pain during orgasm that is associated with the orgasmic contractions of the uterus and vagina becoming less rhythmic and coordinated (Demeter, 1998; Miller et al., 1999).

The refractory phase is especially affected in older men. The time right after orgasm (the resolution phase), when a man returns to the unexcited phase, is of a shorter duration. The time that it takes a man to regroup (the refractory period) before he can achieve another orgasm can be anywhere from 12 to 24 hours or longer. This period increases as a man becomes older. Women tend not to have refractory phases, but aging may cause a lack of cervical dilation (Beers & Berkow, 2000; Demeter, 1998; Miller et al., 1999).

Other changes that occur with aging in women include the shortening and narrowing of the vagina as well as less acidic vaginal secretions, increasing the likelihood of infections. Cystitis is more common in older women in the presence of atrophic urethritis. Decreased estrogen levels may also lead to a decrease in clitoral size, stress incontinence, and a graying and thinning of pubic hair. Estrogen replacement therapy pre- vents or reduces many of these problems. Estrogen replace- ment may also increase the risk of some cancers and heart attacks in women with heart disease and therefore must be used with caution. Women who remain sexually active have fewer problems with maintaining their sexual activity and genital health, prompting some researchers to again question how many of these changes are a result of aging or para-aging phenomena such as illness, disuse, or medication (Beers & Berkow, 2000; Demeter, 1998; Miller et al., 1999).

There are several normal physical changes in men. There is a decreased production of testosterone, which stabilizes around age 60. Likewise, the testicles decrease in size and firmness, sperm production is reduced, and the prostate

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increases in size. In addition, men may notice that preejaculatory fluid production is less. Erections may be less durable and less firm. Unlike women, men do not experience an equivalent of menopause and often remain fertile through- out life. Although sexual dysfunction is not a part of aging, erectile dysfunction is a common concern for many men (Leiblum & Segraves, 2000). Although the incidence of erec- tile dysfunction increases with age, aging is not the cause. More likely, underlying medical conditions and medications are to blame. Emotions also can affect erectile functioning (Beers & Berkow, 2000; Demeter, 1998; Spence, 1992). If a man fears impotence, he may often become too anxious to become aroused. Widower’s syndrome is the temporary impotence experienced by some men on remarriage follow- ing the death of their first wives and is more likely to occur if a former wife’s prolonged illness demanded sexual abstinence (Rossi, 1994).

When reviewing generally accepted sexuality changes, remember that they are based largely on the observation of a very small group of individuals conducted more than three decades ago (Masters & Johnson, 1966). Much has changed, including general health and an extended life expectancy. Currently, over one fourth of the U.S. population is 50 years of age or older, and about one eighth is over age 65 (Rossi, 1994). Menopause status has a smaller impact on sexual functioning than health or other factors (Avis, 2000). The same appears true for men. Illnesses such as heart disease, stroke, diabetes, depression, and alcohol abuse have a greater impact on sexual functioning than aging (Tallis, Fillit, & Brocklehurst, 1998).

SOCIETY AND LATE-LIFE SEXUALITY

Societal expectations seem to have more of an actual effect on sexuality in late life than physiological changes. Many of the commonly held theories of aging profoundly affect sexual behaviors as we age. According to the sociological view of the normative timetables of the life course, sexual interest should begin in midadolescence and reach full expression during midadulthood, coinciding with the height of fertility and physical attractiveness. Therefore, sex is believed to be the prerogative of youth. This view partly arises from tradi- tional values that equate sexuality with procreation. Because pregnancy and childbirth are not part of older persons’experi- ences, older persons are believed not to need or want sex (Rossi, 1994). This attitude is a reflection of the larger problem of ageism.

It is helpful to gain a historical perspective on culture’s observations of sexuality in late life. In 1969, Robert Butler, the first director of the National Institute on Aging, first coined the term ageism to describe the process of the system- atic stereotyping and discrimination of the elderly (Palmore, 1999). Ageist attitudes have their basis not only in popular

media but also in historical perspectives. In reviewing percep- tions and attitudes from the Middle Ages, Covey (1989) found that although little had been written historically about elderly sexuality, what did exist was overwhelmingly nega- tive. A double standard was also revealed that painted older men’s participation in sexual activity as humorous or foolish, whereas older women’s participation in sex was viewed as unnatural and evil. For example, older men were thought to have no capacity for sexual relations, and those who were able to maintain active sex lives were believed to have excep- tional qualities that helped them gain social status and even increase their life spans. In contrast, older women were thought only to be able to have sex in their later years if they were able to trick men into going to bed with them, a feat so abhorrent that it required the aid of witchcraft. The religious prohibitions of the Middle Ages mirrored popular beliefs against sexuality in the elderly. At the core was the belief that sexual intercourse was designed for only procreation. This doctrine promoted the belief that older adults who had sex were engaged in a sin (Bullough, 1976) Thus, the historical basis of wicked witches and dirty old men in popular culture is clear (Hillman, 2000).

Modern Western society sees aging in part as a process of dying and the elderly as defective or decrepit (Palmore, 1999). The elderly are believed to be impotent or asexual (Brogan, 1996). Yet many cultures admire the characteristics of old age. In a groundbreaking study of more than 106 cul- tures, Winn and Newton (1982) illustrated that many beliefs about sexuality in late life are simply stereotypes. Less than 3% of the cultures studied had prohibitions against sex among the elderly. In fact, 70% and 84% of the societies reported sexual activity among their older male and female members, respectively. It was found that in many Eastern and Middle Eastern cultures, men commonly engaged in sexual relations well beyond the ages of 100 and 80, respectively. African cul- tures maintained that impotence was not a normal function of old age but an unnatural loss of ability from illness or witch- craft. In the majority of these traditional cultures, menopause was not associated with either more or less sexual activity among older women. In certain African and Asiatic cultures, an older woman’s physical attractiveness appeared unrelated to her sexual status: Toothless older women were considered as sexually desirable as younger women. In addition, although a double standard appeared to operate with regard to elderly sexuality, it appeared to be in the opposite direction of typical Western traditions. Specifically, older women were more likely to engage in sexual relations and were often described (in more than one fourth of the cultures) as becom- ing less sexually inhibited and more sexually aggressive with age. In certain South American and Eastern cultures, older women were designated as teachers for sexually inexperi- enced young men. An ancient Turkish proverb provided by Hillman (2000) illustrates the general positivity espoused by

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the majority of traditional and preindustrial cultures: “Young love is from earth, while late love is from heaven” (p. 8).

Health providers are not exempt from ageist attitudes. Even some physicians, who should know better, often assume that sexuality is unimportant in late life (Butler, 1975), as do many nurses (Booth, 1990). The American health care sys- tem also perpetuates ageism by focusing on acute care and cures rather than chronic care, which older adults need. It is also done covertly by denying or limiting services, by not including aging issues in training materials or educational offerings for providers, and by not requiring geriatrics train- ing in medical schools even though older adults constitute a significant proportion of their future patients. Ageism, how- ever, is not the only obstacle to the expression of sexuality that people face as they age. Some of the other barriers include the lack of a partner, sexual dysfunction, the attitudes of adult children, altered body images, previous attitudes toward sex, the attitudes of peers, religious prohibitions against sex out- side of marriage, depression, a lack of autonomy of choice, a lack of privacy, marital conflict, and libido mismatch. Levy (1994) suggested that aging individuals require a focus on time, energy, and social connections because they experience the normal everyday stresses of living, as does the rest of the population, as well as the added burden of cultural bias regarding their sexual expression.

LATE-LIFE SEXUALITY AND NONTRADITIONAL RELATIONSHIPS

It is important to remember that older adults are involved in both traditional and nontraditional romantic relationships, including gay, lesbian, and cohabiting relationships. Alterna- tive sexual lifestyles carry their own challenges in all life stages, but aging sexuality seems to present special problems. Many of the barriers include challenges similar to those faced by other aging adults, including institutionalization, the lack or loss of a partner, ageist attitudes, and loneliness. Kelly (1977) showed that many enjoy stable relationships in later life and face the same problems as other elders, especially a fear of the loss of significant others and institutionalization (Burnside, 1988). Often, these challenges are magnified by conscious and subconscious cultural bias against alternative sexual lifestyles. Elderly same-sex or unmarried couples may be separated in nursing homes or denied visitation usually reserved for “relatives.” They may lack the family or social support offered to heterosexual or traditional couples upon the loss or death of a spouse. Especially among gays, many fear that in a lifestyle that seems to value youth and beauty, one’s sexual attractiveness will be lost or, worse, transformed into something pathetic. Controversy also persists among cli- nicians and researchers regarding various issues such as the adoption of gay or bisexual identities later in life, particularly among women, and the existence and impact of outside

affairs within the context of long-term marriage (Hillman, 2000).

Many of these fears or beliefs can be seen as extensions of more obvious ageist attitudes. Sex, as the dominion of youth, is no more a reality among aging homosexuals than it is among their heterosexual counterparts. Biases against same- sex relationships, premarital sex, or extramarital sex are often founded on societal, peer, and religious constraints. Interest- ingly, researchers (Berger, 1995; Francher & Henkin, 1973; Friend, 1990; Kimmel, 1978) have theorized that older adults who have experienced societal prejudice may actually be more resistant to the internalization of ageism. Developmen- tal and demographic changes associated with aging may actu- ally work to the advantage of gay elders (McDougall, 1993). It is much more acceptable for two older men or women to live together as roommates than it is for younger same-sex couples. In fact, society seems to accept that people want and need companionship. This belief, coupled with its ageist assumptions that older adults do not engage in sex and that older gays and lesbians do not even exist as a group, allows older same-sex couples to live together without causing any undue distress or homophobic anxiety among heterosexual members of the community. Furthermore, the belief that the elderly are weak or ill often allows two older women or men to walk arm in arm without others thinking them homosexual but, rather, simply helping each other (Hillman, 2000). Still, we must remember that actual research is lacking, and gener- alizing from empirical studies of younger or more traditional cohorts may be just as potentially dangerous as anecdotal data or no data at all.

THE INSTITUTIONALIZED ELDERLY

Abbink (1983) stated that intimacy is a need that manifests from conception to death, and it does not decrease in intensity or significance through adulthood. It is maintained not only by sexual intercourse but also by touching, stroking, patting, hugging, and kissing and emotionally by the sharing of joy, sorrow, affection, ideas, and values.

Intimacy needs among the institutionalized aged require special attention because society is particularly intolerant of the sexuality of institutionalized adults (Ehrenfeld, Bronner, Tabak, Alpert, & Bergman, 1999). Stiffl (1984) suggests some considerations to remember with this population, such as (a) being aware of isolation and sensory deprivation; (b) the need for touch for social reasons; (c) the need to build sex- uality into spiritual and emotional well-being rather than sep- arating it; (d) the understanding that all meaningful sexual relationships are not heterosexual; (e) accepting masturba- tion, providing touch along with “feeling” objects to handle, fondle, and hold; (f) realizing that live pets provide great sen- sory stimulation; (g) encouraging music that is romantic, sen- timental, sensuous, and erotic; and finally (h) encouraging the

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opportunity for the sexes to meet, mingle, and spend time together without structuring trysting times or places too rigidly.

LATE-LIFE SEXUALITY AND HEALTH CARE PROVIDERS

Sexuality at all ages is an issue for mental and medical health providers, but in late life, it poses particular challenges. Conscious and subconscious prejudices, a lack of education and knowledge, reticence to question elders about sexuality, and societal and religious taboos against sexual behavior and its discussion among this age group must be faced and over- come. The elderly face many sexual challenges as they age, the most important of which is a lack of information. Con- trary to popular belief, older people want to talk about their sexuality and have many questions whose answers are not often easily found. Sexual interviews should include infor- mation about normal sexual changes in functioning and the fact that sexual problems are not necessarily organic in origin. Couples should receive information about the stress of chang- ing roles and the opportunities for a renewed emphasis on companionship and intimacy (Trudel, Turgeon, & Piché, 2000).

Future trends include an increasing number of elderly in the general population; changing attitudes in society and the media; increasing sexually transmitted illnesses, including HIV/AIDS; the impact of less traditional gender roles on aging sexuality; and the long-term effects of sexual trauma on sexual functioning. Mental health and medical providers will be increasingly called on to find solutions. Continued research and commitment to learning more about sexuality in late life will help counselors, physicians, and other health care professionals meet these challenges.

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Thomasina H. Sharpe, M.D., is the medical director of the Univer- sity of South Alabama’s Student Health Center. She has taught fam- ily medicine at the University of South Alabama’s College of Medicine for 5 years. She is a board-certified family physician, and her residency training was at East Tennessee State University in Bristol. She lectures on adolescent and geriatric topics.

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