by Harriet Hodgson

 
"The publisher wants me to tell personal stories," I told my husband at dinnertime. "I’m trying to include at least two stories in each chapter."
     "What chapter are you working on now?" he asked.
     "Sexuality and intimacy."
     My husband almost dropped his fork. "You’re not going to..."
     "No, I’m not going to tell stories about our sex life," I assured him. "But I am going to tell some things about our relationship."
     "That’s ok" he said, and we immediately got into a conversation about our marriage. Friends often comment on what a loving couple we are and this makes us feel good. We think we know why our marriage works, but we aren’t sure, and have decided not to overanalyze it.
     I think we have a good marriage because we knew each other well before we married. We listen to each other and this has led to mutual respect. Forty-one years together haven’t eliminated the element of surprise from our marriage. We make each other laugh. Best of all, we know we can always count on one another. My husband is my champion and I am his.
     Sexuality is part of our lives. Younger people may not believe this, however, because they don’t know much about sexuality in the aging. Our society seems to think young people are the only ones with sexual feelings. And sexuality is, by itself, a complex topic.
     Fran Kaiser, MD, author of "Sexuality in the Elderly," thinks the topic covers attitudes, behavior, practices, and activity. Many people believe that loss of sexuality comes with age and this belief is false. Sexuality is part of the human condition and continues throughout life. It is nature’s way of ensuring the survival of the species.

Sexuality Is Cumulative
There is no age at which thoughts about sexuality and sexual activity end, according to Kaiser. Experts say our past experience influences future sexual behavior. If you have a passionate relationship in your younger years, chances are you will have a similar sexual relationship in your later years. As Kaiser writes, "Another ‘predictor’ [of sexuality] appears to be sexual interest, enjoyment, and activity in younger years."
     The mind is the body’s main sexual organ. When I look at my husband I see a man approaching retirement age. I also see a man who was a James Dean look-alike in his youth, a man who bought me gifts on his birthday, the Air Force officer who received the Bronze Star for valor in Vietnam, a loving father to our daughters, a dedicated health professional, and a sweet grandfather who plays games with the twins. I see the experiences that made the man.
     My husband has a similar reaction when he looks at me. He sees the 17-year-old woman he met two weeks after starting college, a person who loves to learn, a competent cook, a community volunteer, an amateur decorator, an adoring grandmother, and a nonfiction writer.
     We see each other through the colorful, changing kaleidoscope of life experience. Time has increased the sexual excitement we feel for one another. Being with my husband makes me feel 17 again. Despite our respective health scares, we are in pretty good health, thanks to modern medicine. We have been blessed. But health is a barrier to sexuality for many aging people.

Barriers to Sexuality
Diana Wiley and Walter Bortz II studied sexuality and report their findings in "Sexuality and Aging—Usual and Successful." They began their study with a three-part series on sexuality at the Palo Alto, California, Senior Center. An average of 58 people attended the series.
     Wiley and Bortz surveyed the attendees to get some personal information on sexuality. Six months later they sent a follow-up questionnaire to the attendees. The questionnaire topics included the importance of kissing, oral sex, manual genital stimulation, sexual intercourse, orgasm, loving and caring, and satisfying your partner.
     Current findings were compared to past findings. Wiley and Bortz say their current findings about sexual enjoyment are more complex than the ones gathered 10 years ago.

• Roughly 32 percent said the frequency of sexual activity had not changed in 10 years
• 60 percent reported a decrease in sexual activity
• 8 percent reported an increase in sexual activity
• More males (71 percent) wanted increased sexual activity
• 52 percent of females said they wanted an increase
• About 50 percent of both males and females said they thought less about sex now as compared to a decade ago
     "Whereas our follow-up questionnaire showed no real change in sexual behaviors, there was a substantial expression of increased knowledge, confidence, and sensitivity," the researchers write.
     Illness, relationship problems, and erection difficulties were some of the causes of decreased sexual activity. The death of a spouse may close the door on the known sexuality of the past and open the door to sexual exploration. Older women who don’t have a male partner or the prospect of one may express their sexuality with other women.
     In her book, Be An Outrageous Older Woman, Ruth Harriet Jacobs, Ph.D., says this expression of sexuality may be overt or sublimated. She lists some of the ways older women may express sexuality: intercourse with a husband, vacationing with male friends, self-pleasure, reading sexual novels, seeing sexual movies, joining singles groups, focusing attention on children and grandchildren, choosing celibacy, and marrying again.
     Lesbians may look for another lesbian partner after a partner dies. Jacobs says lifelong lesbians face the same kind of sexual deprivations as heterosexual women. "Maybe I have shocked you with my frank chapter," she writes. "But I could back it up by references in the scientific literature."
     Medication, environment, and chronic illness are also barriers to sexuality in the aging. For some, living in a nursing home is a sexual barrier. Further complicating the issue is the fact that many nursing home employees have little or no sexuality training.
     Chronic illness, financial problems, and the vulnerability of age force some parents to move in with their adult children. This arrangement tests the old and the young. Living with children can put a damper on the parent’s sexuality and their children’s as well.
     Increasingly, grown children are moving back home to regroup. The timing is poor. Just when parents have gotten used to their honeymoon nest, they have adult children underfoot, and the hassles that come with it. "He’s up watching TV half the night," a father complained. "We can’t sleep, let alone have sex."
     Life-threatening illness is another barrier to sexuality. Let’s say one partner has a heart defect that requires surgery. The surgery is successful and the patient is restored to good health. Long after surgery, however, the fear of relapse is still present. This mental barrier may alter sexual behavior.

The Sexuality/Health Equation
Stephen Holzapfel, MD, CCFP, of the Department of Family and Community Medicine at the University of Toronto Medical School, studies sexuality in the aging population. He views sexual expression in the aging as a predictor of general health. In other words, people who have good health continue to be sexual. "The greatest barrier to being sexual in old age is lack of a healthy sexual partner," he writes in his study "Aging and Sexuality."
     Menopause affects sexuality in older females. Women spend about a third of their lives in menopause, according to Holzapfel, and that is a large chunk of time. Medication may also alter our sexual performance. People who are 65 years old and above take roughly three times as many prescription drugs as younger people. Holzapfel notes that medical treatment—medicine, surgery, rehabilitation—is the most common cause of sexual dysfunction.
     Many doctors are reluctant to bring up the topic of sexuality with their patients because it is embarrassing. Whether we are embarrassed or not, aging people are sexual people, and that is a fact. The sexuality equation has many components and they may, or may not, balance. Society’s view of sexuality is one of these components.

"I’m Sexually Invisible."
When I told a friend of mine that I was going to write a book about aging, she immediately asked, "What’s in it?" I listed some of the topics, including sexuality, and she interrupted me. "That’s good, because I’m sexually invisible," she said. "Nobody thinks I am a sexual person anymore. It’s awful."
     Once you are sexually invisible you may also become generally invisible. Sexual invisibility is like a leaking faucet; it begins with one drip, or one experience. More experiences come, faster and faster, until there is a constant stream of sexual invisibility. You may be ignored while standing in line, for example, or patronized by younger co-workers.
     A recent trip to the drive-in bank made me feel totally invisible. I wrote a check for 75 dollars, put it in the tube, and sent the tube to the teller. The tube came back empty, so I pressed the service button. Nothing happened. I pressed the service button again and, still, nothing happened. Although I could see the teller, somehow she couldn’t see me.
     In desperation, I started waving at the teller. The intercom came on with a crackling sound. "May I help you?" she asked in an annoyed voice.
     "Yes, you can give me my money," I said. "I wrote a check for 75 dollars and the tube came back empty."
     The teller was startled. "Just a minute," she answered. A few minutes later the tube came back with 75 dollars in it. "Sorry about that," she said. "I didn’t think anyone was there."
     Didn’t think anyone was there? I was sitting in a red car, pressing the service button repeatedly, waving at the teller, and she didn’t think anyone was there? Her apology was vexing. Age discrimination is the real issue here, society’s way of saying we aren’t worth noticing.
     Unlike the Oriental cultures, which respect age, our society views the aging as dried up, useless, sexless people.
     At home I am a cherished wife. My husband and I show affection in front of the twins so they know their grandparents love each other. The twins are getting the idea. We were playing a self-esteem game with them and my husband’s game piece landed on a square that read, "Say something nice about the person next to you."
     He gave me a hug, and said, "You are beautiful."
     Our granddaughter beamed. A few minutes later, her game piece landed on a square that asked her to list something that made her happy. Her reply: "When people say I’m beautiful."
     "And you are beautiful," I added.
     Some day, and it will probably come sooner than I expect, the twins will figure out that we are sexual people. Until that time comes, they know love is the cornerstone of our family, our love for each other, our love for our children, and our love for them.

Sexual Dysfunction in Men
Two major problems, erectile dysfunction and Widower’s Syndrome, prevent many men from expressing their sexuality. The causes of erectile dysfunction include vascular disorders, medication (such as diuretics and hypertensives), tobacco, marijuana, alcohol, neurologic disorders, and psychological problems.
     Widower’s Syndrome "may result from unresolved guilt and grief toward the deceased partner, and subconscious repression of sexual feelings," according to Fran Kaiser, MD. Painful memories may also contribute to Widower’s Syndrome. Grief is a process that takes time. Sadly, time may not heal this wound.

Sexual Dysfunction in Women
Women who have difficult or painful intercourse may become sexually dysfunctional. Sex becomes something to fear, rather than a joyous celebration of life. Lack of vaginal lubrication may also make intercourse painful. Incontinence may also inhibit sexual desire, according to Kaiser.
     Hysterectomy, which has been performed on one-third of the women in our country over age 60, is not associated with sexual dysfunction. However, Kaiser says the women who associate a hysterectomy with loss of femininity may experience some problems.
     Vaginismus (painful spasms of the vaginal muscles) may also contribute to sexual dysfunction. Yeast infections, which are fairly common in aging women, also play a part in sexual displeasure. As you might expect, menopause has a profound effect on female sexuality.

Menopause
The treatment for menopause continues to improve. Gloria Bachmann, MD, describes treatment in her study, "Influence of Menopause on Sexuality." Hormone replacement therapy (HRT) is one focus of her study. As she writes, "The importance of hormone replacement therapy in four areas of menopausal health is quite clear: cardiovascular health, prevention of osteoporosis, control of vasomotor symptoms, and maintenance of urogenital health."
     Bachmann discusses the effects of decreased estrogen levels on sexual function and they are considerable:
• Decreased support of pelvis (which affects sexual satisfaction)
• Loss of lubrication (which may make intercourse painful)
• Changes in body configuration
• Skin changes (touch may be less pleasurable)
• Breast changes
• Muscular and skeletal loss
     Many people assume males are always "sexually ready" and this isn’t true. Bachmann says the male partner may have less sexual interest and this leads to a decline in sexual activity. In contrast, women who have completed menopause may feel sexually freer because they no longer worry about getting pregnant.
     Hormone replacement therapy has been part of my life for more than 15 years. Migraine headaches are a side-effect of this therapy. Although I don’t have full-blown migraines, I have colorful auras —displays of zig-zag lines and flashing lights. The auras can hit at the worst times.
     I was on the way to a conference in St. Paul when an aura developed. It got progressively worse and by the time I reached the city my field of vision had been reduced to a circle. Traffic was heavy and I couldn’t find a place to pull over. Since I was two blocks from my destination, I slowed down, continued on to the hotel, and arrived safely.
     But my circle of vision got even smaller, and I was having trouble thinking. I went to the ladies room before the meeting started. As I was washing my hands I realized the ladies room had shadowy, rectangular depressions on the wall. Artwork in the ladies room? Upon closer examination, I realized the depressions were urinals, and I was in the men’s room.
     I raced out the door, past a man standing at a phone kiosk beside the men’s room entrance. He stopped talking and gave me a disgusted look. "OK, I made a mistake," I declared. "These things happen."
     The experience came to mind after I read Dr. Fran Kaiser’s study, "Sexuality in the Elderly." "Until recently, sexual activity in older adults has been considered to be inappropriate, immoral, deviant, or at best, bizarre," she explains. Apparently the man in the phone kiosk thought I was a sexual deviant, voyeur, or pervert.
     The truth of the matter is that I am a grandmother on hormone replacement therapy who had a migraine aura that prevented me from reading the sign on the door. Surely I am not the first woman to make this mistake and I probably won’t be the last. At least I can laugh about it.

Male Menopause
Of course men don’t experience physical menopause, but they do experience some of the psychological symptoms. Doctors are becoming more aware of male menopause and its effects on sexuality. Douglas Schow and his colleagues explain the condition in their study, "Male Menopause: How to Define It, How to Treat It."
     The symptoms of male menopause sound a lot like the symptoms of female menopause: hot flashes, depression, sleep problems, lower sex drive, general weakness and lethargy, weight gain, and loss of bone mass. You can imagine the problems that develop when both partners have these symptoms.
     Schow and his colleagues think "male menopause will become an increasingly important issue for primary care physicians because the number of men in the United States between the ages of 45–70 years is expected to grow from 46 million in 1990 to 81 million by 2020." They also think more research is needed into the psychological effects of male menopause.

New Definition of Impotence
A new definition of impotence was proposed in a National Institutes of Health Consensus Conference article. The NIH conferences have dual purposes: one, to evaluate existing scientific information, and two, to advance public understanding. Since impotence had become a term with "pejorative implications" the NIH recommended the term "erectile dysfunction."
     This is a more accurate term, according to the NIH. Millions of men in our country suffer from erectile dysfunction and the Consensus Conference says:
• Erectile dysfunction increases with age but it isn’t inevitable
• Embarrassment keeps patients and health professionals from discussing the problem
• Many cases can be managed with medical therapy
• The diagnosis and treatment of erectile dysfunction must be specific
     Erectile dysfunction has a ripple effect, altering partner, family, and work relationships. Raul Schiavi, MD, and Jamil Rehman, MD, detail the causes of erectile dysfunction in their study, "Sexuality and Aging." They say physical health, fear of failure, and relationship with a sexual partner all affect erectile dysfunction. "Marital conflict, problems of commitment and intimacy, power struggles and lack of trust" also contribute to the problem, according to researchers. They point out that men and women tend to blame the man for the cessation of intercourse. Fortunately, many treatments for sexual dysfunction are available.

Treating Male Dysfunction
Before he or she recommends any treatment, a doctor will do a complete physical exam and assess the drugs the patient is taking. Stephen Holzapfel, MD, CCFP, author of "Aging and Sexuality," says drugs can cause sexual dysfunction in men. He includes cardiac, gastrointestinal, neurological, endocrine, oncological, psychiatric, and recreational drugs in his observation.
     For example, beta blockers, which are taken to lower blood pressure, may interfere with male erections. Schiavi and Rehman also point out that the erections of aging men may not be as stiff as they used to be. Certainly, sexual dysfunction strikes at the heart of masculinity.
     Researchers continue to search for solutions to male dysfunction. Associated Press writer Lauran Neergaard reports on a new medication in her article, "Impotence Pill Gains Approval." In March of 1998 the Food and Drug Administration (FDA) approved Viagra, produced by Pfizer, Inc., to treat impotence. Neergaard notes that Viagra is the first nonsurgical treatment for male impotence that doesn’t involve injections or inserting something into the penis. Since Viagra was approved the cost of the pills has risen steadily. The medication is supposed to be used once a day, about an hour before sexual intercourse. Medical experts think Viagra may spur more males into getting help. "Only 5 percent of the estimated 10 million to 20 million impotent Americans get treatment," explains Neergaard, "but the pill could increase that number to 20 percent very quickly."
     The public seems to be ignoring the fact that Viagra is not an aphrodisiac and helps dysfunctional men only. An ABC World News Tonight report said demand for the drug has been "enormous." According to ABC, 20,000 prescriptions for Viagra are being filled per day in the United States, and the drug has nearly tripled in price. Viagra has serious side-effects, said ABC, especially when taken with nitrates.
     Men who have a low sperm count may benefit from testosterone therapy. This therapy may be oral, intramuscular, or transdermal. As with any therapy, testosterone therapy has some risks, things like weight gain, sleep apnea, and cardiovascular risks.
     Douglas Schow and his colleagues cite these and other risks in their study, "Male Menopause: How to Define It, How to Treat It." According to the researchers, aging men usually have decreased serum testosterone levels. However, the researchers think this "plays an insignificant role in the decline of sexual activity."
     The question is, should aging men have testosterone replacement therapy? "Testosterone’s role in restoring the lost vigor and body composition of youth is questionable," the researchers note. Routine androgen therapy needs to be studied more, say the researchers, and the risks need to be weighed with the benefits.

Impact of Stress on Sexuality
Whether it is unpaid bills, kids on drugs, or added job responsibilities, stress has an impact on sexuality. Phil was a research scientist at a major corporation. His research was so complex that few people understood it, not even his colleagues. Phil’s wife had a vague idea of his research, at best. Brilliant, preoccupied, and in his own world, Phil paid scant attention to his appearance, and often had no recollection of driving to the laboratory. Often he worked late into the night. Sexuality became a low priority in Phil’s life.
     "He is so absorbed in his research that sex doesn’t interest him," his wife commented.
     When Phil was interested in sex, he was emotionally absent. Although the couple had children, Phil wasn’t very involved in their care, or in caring for the couple’s sexual relationship. The couple drifted apart until they had parallel lives.
     Stress may affect sexuality in unusual ways, ways that require professional help. Contact your doctor if you think stress is affecting your sexuality. Your doctor may refer you to a stress-management program. Get your stress under control as quickly as possible because it can lead to high blood pressure.

Improving Sexuality
Stress management is just one way to improve your sexuality. An essay in the Mayo Clinic Health Letter called "Sexuality and Aging" contains some other suggestions. First, older people may have to do some planning before they have intercourse. Long-term estrogen replacement has helped many women. Men have a range of medical options: testosterone medication, vascular surgery, self-injection therapy (injecting medicine into the penis) and new medications. Professional counseling is also an option for both partners. Many couples have improved their sexual relationship by getting away from the daily grind.
     Years ago, one of my husband’s colleagues told him to attend all of the conferences he could. "My wife and I did that," he said. "Every trip was a honeymoon." Shortly after he made this comment his wife died.
     We have followed this advice, traveling when we can, going away for the weekend, or staying home and puttering about the house. Sometimes we just sit on the couch and read. These times are indescribably beautiful. Over the years we have learned to revitalize our sexual relationship in a variety of ways:
• Saying "I love you" every day
• Going out for a romantic dinner
• Enjoying a romantic dinner at home
• Laughing together (my husband cuts out cartoons from the newspaper and gives them to me)
• Surprising each other with small gifts (a hobby magazine, a flowering plant, etc.)
• Leaving love notes around the house
• Giving each other massages
     Education seems to be the key to all solutions. You can’t benefit from new medical treatments unless you know about them. You can’t be helped by an intuitive counselor unless you know what counseling is available. The increasing life span will make sexuality education more important in the years to come.

Sexuality Education
The National Institutes of Health Consensus Development Panel on Impotence has discussed the importance of public education on sexuality. The NIH panel thinks sexual information needs to be distributed via:
• Accurate newspaper and magazine articles
• Radio and television programs
• Special programs at senior citizens centers
• Accurate diagnosis and treatment
     Television programs are showing older people in a sexual context, but the portrayals are limited, and some border on ridicule. The print media seems to be doing a better job in the sexuality education department. My hometown newspaper, the Rochester Post-Bulletin, published an article, "Courting the ‘Golden Years’" by Dawn Schuett.
     She cites some U.S. Administration Aging statistics in her article. Life expectancy is 79 years for women and 72 for men. This means "seven out of 10 women born during the ‘baby boom’ will outlive their husbands," writes Schuett.
     In a companion article, "Seniors Put a New Spin on Dating," Schuett says dating is a whole new world for women and men 60 years old and older. These people are young at heart. You would think this would be cause for celebration, but some adult children don’t like to see their parents dating. Fixed incomes may put a crimp on dating and women often pay their own way. I think dating in later years shows trust in life. After all, life is for living.

Smart Aging Tips
• Learn more about sexuality in the aging.
• Think of sexuality as a cumulative experience.
• Become aware of the barriers to sexuality, such as health problems, lack of partners, effects of medicine, and Widower’s Syndrome.
• Be aware that sexuality is a predictor of general health.
• Stand up for yourself and don’t let yourself become sexually invisible.
• Learn about the causes and treatment for sexual dysfunction.
• Discuss the symptoms of menopause and male menopause with your doctor.
• Get professional counseling if stress is interfering with your sexuality.
• Find ways to revitalize your sexual relationship.
• Stay attuned to the medical advances regarding sexuality.
• Give the gift of touch.
• Remember that love is sexual, intimate, and ageless.