The chaste older person. The dirty old geezer. The horny old broad. Stereotypes all.
"The stereotype is grim," says Walter M. Bortz II, MD, author of We Love Too Short and Die Too Long. "The reality is that older people are a lot sexier than younger people think. The common notion is that when you are old you don't -- and maybe shouldn't -- have sex. Our studies have shown that older people are sexier in attitude and performance than they have been credited for."
And that performance has some interesting documentation.
"You must realize that in the U.S. the biggest use of prostitutes is on the day Social Security checks come out," says John Morley, MD, director of the division of geriatric medicine at St. Louis University.
So who's responsible for the myth that sex becomes unimportant as one ages?
"People who are older get very little support from the younger generation about sex," says Joani Blank, MPH, author of Still Doing It: Women and Men Over 60 Write About Their Sexuality. "Young people identify everyone in the next generation with their parents, and of course they don't have sex."
The danger is that people come to accept these stereotypes as true. They then risk losing one of the most important parts of their lives -- and their health.
"Sex is good for you," says the 63-year-old Blank, a sex educator for more than 25 years. "You should continue to have good sex for the same reason you should continue to get good exercise: It's taking care of yourself. Wake up your body again if it has been shut down. Do it whether you feel like it or not."
Bortz, a specialist in internal medicine at the Palo Alto Medical Clinic in California and a clinical associate professor of medicine at Stanford University School of Medicine, goes even further:
"We should as a moral responsibility continue to be sexually active," he says. "Is it OK for a 75-year-old widow to say, 'Sex is not on my agenda any more?' I would challenge that and say, 'Maybe you should make an overt effort to make the rest of your life as full as you can.' And that includes being daring, flaunting the stereotype.
"Not infrequently an older woman will tell me, 'I just don't give a damn about sex any more,'" Bortz continues. "I say, 'You should, because it is important for your life quality.' She will say, "Well, is it OK to stop making love if you feel like it?" And I say, 'No.' We agree it is not OK not to exercise. If we agree sex is good for you, you shouldn't stop -- regardless of apathy."
Finding What Works for You
Sex for seniors is not the same thing as sex for young people. The concern is with recreation rather than the possibility of procreation -- and for same-sex couples, the stress is less on performance and more on satisfaction. This allows more room for expanding one's sensuality -- an important aspect of sex when the natural aging process may mean changes in sexual function.
"We don't necessarily get worse, but our physiology changes as we get older," Bortz says.
"One myth to put aside is that sex equals intercourse," Blank says. "I call it the tyranny of sexual intercourse. Alternatives to intercourse are not just for people who don't want to get pregnant or get a disease. The most healthy thing is for people to put aside the idea that if intercourse isn't working for you, you can't be sexual. Intercourse should never be the goal. If some sexual activity is uncomfortable or doesn't work, try something different."
"There are a wide range of sexual enjoyments that people practice, and we as physicians should not assume that, because all we know is the old missionary position, our patients are bad for liking other things," Morley says. "Our job as physicians is to facilitate and improve and counsel where possible."
This may mean different things for different people.
"Wherever you are starting from, expand," Blank urges. "My biggest pleasure is when I see somebody who has been really shut down and helping them make baby steps toward changing their sex lives. We have learned so much from people in the disability community. I know a quadriplegic man who has no feeling below the neck, but he can have orgasms from having his neck nuzzled. You adapt. For example, if your partner is very overweight, there are a lot of things you can't do. So what? There are a lot of things you can do. Find a way to enjoy yourself with whatever limitations you may have."
Restarting Stalled Sexual Energy
What can you do if your sexual pilot light has gone out? For many people, the answer may be communication -- something that doesn't come in a pill bottle.
"The worst sexual dysfunction in this country is our inability to talk about sex," Blank says. "To make the leap from not talking to talking is huge. People have to know they are not the only one who is considering being sexual. They need to know that they can do it without any risk to their health, and more importantly, with no risk to their self-esteem. One of the problems with people who are now older is there is even less talk about sex than there was before.
"The cure for the sexual problems and lack of interest in older people is the same as it is for younger people," she continues. "Get informed, and find a way to talk about it with somebody, not necessarily a therapist but a friend or somebody. Screw up your courage and talk to them."
Communication can also help overcome another problem -- feeling that nobody will find your older body sexy.
"If we are not sick and debilitated by whatever is getting to us in our old age, then there is no reason we shouldn't be feeling good about ourselves sexually and think of ourselves as potentially being attractive to others," Blank says. "Self-image is a really important part of it. If my self-image is good,
I can at least think about being attractive. I don't have any difficulty telling a sex partner that I have problems with some things about my body and don't feel comfortable taking all my clothes off."
Once self-esteem is better, a person can begin to explore their newfound sexuality. Blank and Bortz each recommend masturbation -- for both men and women -- as a good starting point.
Steps to Better Sex for the Older Woman
Not surprisingly, maintaining sexual function is different for men and women.
"Men are mostly concerned about erections," Bortz says. "For women, the concern is opportunity."
"I was on an airplane sitting next to a 90-year-old woman and she said, 'What do you do' and I told her I was a gerontologist with an interest in impotence," Morley recalls. "She got more and more interested in what I was telling her, and she said, 'Well, you must have a big clinic of men. So the next time you fix one, give him my card.'"
Bortz says women over 60 should reject the idea that their sex lives must end if their husbands pass away.
"If you don't have a guy, go get one -- don't be embarrassed, or shy, or conform to the idea it is over for you," he says. There is this reigning paradigm that once your man has died it is all over for you. It is a nostalgic, romantic image. But physical touching and romance should be with us until the last twinkle."
One of the disincentives for women is painful intercourse due to thinning of vaginal tissues as estrogen levels decline. Hormone replacement therapy used to be used for this purpose. But with more research linking combination estrogen and progestin therapy to heart disease and breast cancer, hormones are now only recommended for the relief of hot flashes.
Both Morley and Blank recommend the use of lubricants for older women. If condoms or sex toys are used, these lubricants should be water-based and not oil-based.
Finally, Bortz suggests that woman can actively increase their sex drive -- what psychologists call libido. "There are three or four stages in the sex act," he says. "But first comes desire, which is hormonal. Lots of women have flagging desire, and testosterone works for both women and men in this regard."
Steps to Better Sex for the Older Man
For men as well as for women, sexuality begins with desire.
"Libido starts everything," Bortz says. "A man's testosterone level goes down with aging. But most men's aging problems are not testosterone. But this might be the problem, so the first step is to measure the testosterone levels in the blood."
The FDA estimates that there are 4 million to 5 million men in the U.S. with low testosterone levels, a dangerous medical condition known as hypogonadism. But many of these men are not getting testosterone treatment. Morley says new studies put the number of hypogonadal men in the U.S. at 10 million to 15 million.
Even so, both Morley and Bortz warn people to get reliable tests of their testosterone level before attempting testosterone therapy.
"Giving testosterone to every older male would be wrong," Morley says. "Give it to hypogonadal men. There is a large number of studies that show libido will improve in older men when you improve testosterone levels. The reason to give testosterone to older men is not limited to sexual activity. Sex is nice, but living is even more fun. As we get older, memory goes down -- and we males tend to lose our ability to remember at a greater rate than females. We have shown that the single best predictor of poor memory in middle-aged men is low testosterone. And when men are given it back, their memory improves."
Morley has developed a questionnaire that can screen men for possible testosterone deficiency. He calls it the ADAM (Androgen Deficiency in Aging Men) test. It includes 10 questions:
- Do you have a decrease in sex drive?
- Are your erections less strong?
- Do you have a lack of energy?
- Do you have decreased strength or endurance?
- Have you lost height?
- Have you noticed a decreased enjoyment of life?
- Are you sad or grumpy?
- Have you noticed a recent deterioration in your ability to play sports?
- Are you falling asleep after dinner?
- Has there been a recent deterioration in your work performance?
A "yes" answer to either of the first two questions, or a "yes" answer to any three questions indicates that a man should have their testosterone level checked. Morley recommends a direct test known as "bioavailable testosterone," which he finds more reliable than tests for total testosterone or calculations of bioavailable testosterone from other tests.
Bortz agrees that testosterone has been used indiscriminately.
"Way too much testosterone has been given in the hopes it might work," he says. "But it's not the big deal -- the big deal is impotency. This has several components, and the main one is hydraulics. That is where Viagra enters wonderfully, and I cannot vaunt its benefit to mankind highly enough. I think it is one of the most important drugs to come along, and it is quite safe."
Morley notes that Viagra cannot work properly if low testosterone levels are not corrected.
"A hypogonadal male getting Viagra has a soft erection," he says. "You add testosterone and that erection goes up again like he is 20."
Viagra, however, does have side effects such as flushing and headaches. And Morley warns of another possible side effect: color blindness. "When a guy is on Viagra he has to be very careful going through street lights," he warns.
Morley notes that sexual function in men also can be caused by psychological problems such as depression and by a wide variety of diseases. Not the least of these is heart disease, and difficulty in attaining an erection could be an early symptom.
"If you see someone with impotence, the first thing you do is fix all the cardiovascular problems -- it is a very important thing to pick up early," he says.
"The number one drug that causes impotence is tobacco," Morley says. "People who smoke have a smaller blood flow. If you give me [a drug injection] to stimulate an erection and then give them just two cigarettes, the erection will go down. I never had any success in getting my patients to quit smoking until I told them about this."
And sensation, or lack of it, also plays a role.
"How does one keep one's nerves taut and tingly? The phrase 'use it or lose it' comes easily to mind," Bortz says. "There is this phenomenon known as widowers' syndrome, where a man can't get an erection with a new sex partner -- until he practices. That is where Viagra could be used as an operational crutch. The answer to not enough erections is erections. This leads to the idea that there may be a recommended daily allotment for erections."
It may seem obvious, but Bortz stresses the importance of good relationships to healthy sexuality. He sums up his advice for a healthy sex life in three points:
- Stay healthy.
- Avoid medications that reduce sexual function.
- Find and keep a good mate.
Good Sex Is Safe Sex
Sometimes seniors who rediscover their sexuality forget an important rule: Good sex is safe sex.
Safe sex means being responsible for your own health,and the health of your partner. There are a lot of bad bugs out there. And unlike the old days, not all of them can be cured with a simple shot of penicillin. In fact, some can't be cured at all.
Here are a few simple rules:
- Condoms aren't just for contraception any more. If you're sleeping with a new partner, use condoms for each sex act. This includes oral sex. It also includes the use of shared sex toys.
- Consider alternatives to intercourse until you and your partner each receive a clean bill of health.
- Remember that a negative HIV test doesn't mean you aren't infected. That takes two tests six months apart.
Ask your doctor about other ways to make your sex life safer.
The Bottom Line
"If a grandfather clock stops running, your choices are to junk it, fix it, or wind it up," Bortz says. "Aging isn't a disease. Do you feel used up? Well, you could give up. Or you could fix what's wrong and wind back up. My main contribution is that most of what we think is aging is disuse. And that applies strongly to sexuality."