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The field of sexuality and aging is still in its infancy. Emergent issues include the role of the Internet, dating, and divorce among older adults, and sexuality at the end of life.

Once considered a virtual societal myth, it has been established consistently via research and clinical findings that older adults can and do engage in a variety of sexual behaviors, and express their sexuality in a variety of ways. However, new forces in society including drugs such as Viagra for treatment of ED, marketing campaigns that promote a highly sexualized, physically healthy, and ageless ideal, and opportunities on the Internet can bring significant change to the expression of older adults’ sexuality. Dating has changed for older adults, particularly in relation to the limited number of available, older single heterosexual men compared to women, increased rates of divorce, and various online opportunities.

This chapter is designed to review emergent areas of clinical interest and research in adulthood and aging. With increased rates of divorce, cohabitation, and second (and other) marriages among aging adults, issues in couple’s therapy may emerge related to the sharing of resources as well as allegiances to adult children from previous relationships. Although limited empirical research is available regarding its use, the relative anonymity of the Internet offers older adults unique access to sexual health information, erotica and pornography, and social networking including dating. Another emergent area of importance is that of sexuality at the end of life. Although research indicates that sexuality remains important to older men and women in palliative care, few professionals acknowledge or even broach the subject.

The Internet

Older adults represent one of the most rapidly growing segments of Internet users. Adults over the age of 65 account for approximately 13% of the US population, and in similar proportions, represent nearly 10% of all active US Internet users. The number of older adults who identify themselves as active Internet users has recently doubled, with more than 17 million online users over the age of 65 spending an average of more than 48 h a month online (Nielson 2009). Although more men than women over the age of 65 report using the Internet, the number of older women users is increasing steadily each year. The AARP (2010) reports that nearly half of all adults over the age of 50 feel “extremely or very comfortable” going online. In contrast, only 1 in 4 adults over 50 reports that they never used the Internet. Additional findings suggest that baby boomers place greater value upon the ability to access the Internet via a smart phone or other handheld device than younger adults (Yang and Jolly 2008), and that older adults profess only minimal anxiety about the use of technology (Niemela-Nyrhinen 2007). These findings consistently dispel myths that older adults are uncomfortable with, and do not like, using computers or the Internet.

In terms of specific online activities, the Nielsen company (2009) reports that nearly 90% of older adults use the Internet primarily for e-mail. Nearly half of those surveyed reported that they used the Internet to search for health-related information, which could include information related to sexuality (Nielson 2009; Nimrod 2009; Wyatt et al. 2005), and more than one-quarter reported using social networking sites to keep in touch with friends and family (AARP 2010). The third most commonly visited site for users over the age of 65 was Facebook. (Notably, in the year prior to the 2009 Nielsen report, Facebook was only the 45th most commonly visited site among this older age group). More than 70% of older users report that their online social networks are very important to them (AARP 2010). Nearly 10% of all visitors to social networking and blog sites were over the age of 65, with slightly smaller numbers of teenagers following suit (Nielson 2009). In other words, older adults are more likely to use social networking than teens. Although more than half of all older adults access the Internet via a desktop computer rather than with a laptop (26%) or smartphone (8%; AARP 2010), social networking and online interaction with others is clearly important to older adults and is becoming increasingly popular.

Evidence also exists of a significant digital divide within the older adult population. Additional findings from the AARP’s (2010) study of Internet use revealed that Latinos over the age of 50 were significantly less likely to use the Internet, and felt significantly less comfortable using the Internet, than their White counterparts. For example, only 20% of Latinos, compared to 47% of Whites, reported being “extremely or very comfortable” using the Internet. Although more than three-quarters of Whites report using the Internet regularly, more than half of all Latinos report that they have never gone online. It is unclear whether the discrepancies observed between Internet use among older Whites and Latinos can be explained by differences in socioeconomic status, culture, or even the availability of certain Web sites in Spanish. It also remains unclear if there are other significant differences in Internet use among middle-aged and older adults from different ethnic and cultural groups. It is clear, however, that both clinicians and researchers need to be aware of these differences in Internet access and comfort.

The Internet offers a variety of benefits for older adults. In terms of the expression of sexuality, it is a powerful medium for a number of reasons (Adams et al. 2003). The relative anonymity of users is paramount. An older adult can, from the relative privacy of their own home, visit a variety of Web sites and participate in various groups and chat rooms without having to reveal personal information about themselves. Unless an Internet user chooses to submit online photos or use a Web cam, older adults can interact with others without being discriminated against for having gray hair, wrinkles, being over or underweight, having a different skin color, sitting in a wheelchair, or for having some other physical disability (Adams et al. 2003). Curiosity about potentially embarrassing or stigmatizing topics can be explored without being conspicuous. Pornography, sex toys, lubricants, and condoms can be viewed or purchased without having to go out in public to an adult bookstore. Most sites on the Internet are free or at low cost, so for those who have Internet access, most online material is quite affordable.

Certainly, each of these factors poses various pros and cons. Like individuals of any age, older adults can become so involved with online pornography that it begins to interfere with their own personal relationships. Other older adult Internet users, particularly those with some degree of cognitive impairment or a lower level of education, may be more likely to misinterpret health information found on the Internet. Multiple accounts exist of older adults being duped or scammed by online parties who are less than honest or forthcoming. To help address some of these practical issues, the AARP offers valuable information for people who want to explore the Internet with a greater degree of online safety and awareness (e.g., www.aarp.org/technology/how-to-guides).

Online Dating

Although large increases in the absolute number of older adults has occurred as a result of the aging of the baby boom generation, additional changes appear when one considered the sheer number of older women compared to older men. Specifically, by age 75–84, women outnumber men by at a ratio of nearly 2–1. For Americans aged 65–74 there are more than 100 women for every 82 men (Gist and Hetzel 2004). A number of factors may help account for this discrepancy. Women have a longer life span than men, and women tend to marry older men. Thus, married women can typically expect to become widows and live as a widow for many years to come. As a result, the odds are stacked poorly against an older heterosexual woman who wishes to find an available male partner. This discrepancy in population size between older men and women also means that older, heterosexual men will find themselves with multiple opportunities for available partners. (When the author presented some of these findings at a local community presentation, a middle-aged male audience member shouted out from the back of the room, “Woo-hoo! Now you’ve given me a reason to live!”) This virtual glut of single women in the older adult population certainly influences the experience of dating for both older heterosexual men and women.

More than one million older adults have turned to Internet dating sites and services, perhaps in part to the demographic challenges of finding an older, single, male partner. Baby boomers typically hold more liberal attitudes toward sexuality and dating then their previous older adult cohorts, and the Internet can also provide outlets for ­companionships and dating for older adults who may have physical challenges to their mobility or for those who are socially or geographically isolated. In recent years on Match.com, one of the largest online dating sites, the number of new members over the age of 65 has more than doubled (Los Angeles Times 2004). Although generalist dating sites such as Match.com, eHarmony, and Yahoo!Chat accept adults over age 65 as members, additional online dating sites designed specifically for middle-aged and older adults including SeniorPeopleMeet.com, SeniorMatch.com, SeniorFriendFinder.com, ThirdAge.com, BabyBoomerPeopleMeet.com, SilverSeniors.com, SeniorNet.org, and LavaLife.com, among others, now exist with hundreds of thousands of members.

Most dating services, including SeniorNet.org and Sassyseniors.com offer links or membership to LGB elders. Some sites also are available for middle-aged and LGBT elders including cafmoscommunity.com for middle-aged and older gay men and onlinegaydating.co/uk. However, stigma against LGBT adults exists, even online. eHarmony, one of the largest online dating sites, which initially accepted only heterosexual members, was court ordered in 2008 to offer a separate online dating service for LGBT individuals, including LGBT seniors (Axon 2010). Due to the stigma typically faced by LGBT older adults, especially those who may be physically or socially isolated, online opportunities for friendship, dating, and social support can offer significant benefits.

One of the few studies available that provides information about older adults’ online dating profiles and preferences reveals similarities to those observed among younger adult users (Alterovitz and Mendelsohn 2011). An analysis of 600 heterosexual personal ads on Yahoo! revealed that men aged 60–74 and those aged 75 and older were seeking female partners younger than they were. Older female users aged 60–74 were seeking male partners who were similar in age or older, whereas female users aged 75 and older sought male partners younger than they were. All of the males in the study, from age 20 to 80 were seeking physically attractive female partners, and provided information about their status (e.g., income and educational level). All of the female users, including those aged 60 and older, were more selective about selecting a male profile, and placed emphasis upon a potential partner’s level of income and education. So even in advanced age, men appear to value physical attractiveness and youth in a romantic partner, whereas women appear to value personal resources and status over youth. However, beginning at age 75, women appear to deviate from this pattern, and place similar value upon status and relative youth.

Individual reports suggest that many older adults find companionship, dating partners, love, and even committed partners and spouses through various online services and activities. Actual data on member satisfaction is lacking, so most reports remain anecdotal. Individual reports of negative outcomes from online dating also appear. For example, a 64-year-old widow began chatting online with a “Mr. John Smith” from Canada on a Christian Internet dating site. After a few months of chatting, Mr. Smith proposed and asked the widow to send various household goods and money to his address to help him prepare for an online business before their wedding. The woman complied for more than 2 weeks before one of her adult children became concerned and alerted her to the scam. Local authorities then opened an investigation. Another adult daughter wisely prevented her 63-year-old, recently separated mother from sending her new out-of-state, online boyfriend the money to buy an airline ticket to visit for the upcoming holidays. Once the 63-year-old informed her boyfriend that she was unable to send the money for his ticket, all communication from him suddenly ceased. The AARP offers additional sound advice for seniors who wish to engage in safer online dating (e.g. http://www.aarp.org/money/scams-fraud).

Pornography and Online Purchases

It is notable that none of the aforementioned studies, including the large-scale Nielsen (2009) and nationally representative AARP (2010) studies of Internet use, assessed the extent to which older adults used the Internet to view pornography. Virtually no information is available regarding the extent to which older adults communicate in online chat rooms or forums dedicated specifically for sexual activity (and whether those communications are obtained for free or pay), or share sexualized pictures or videos via “sexting.” It is unclear whether the researchers who designed these surveys were told not to include such measures, or whether the researchers failed to consider that older adults might use the Internet for such activities.

Some of the only empirical data available regarding older adults’ use of pornography exists regarding both print and online forms (Kontula and Haavio-Mannila 2009). This nationally representative survey of Finnish adults found that more than half of middle-aged and older Finnish men found pornography arousing. Specifically, 64% of men aged 45–54, 57% of men aged 55–64, and 55% of those aged 65–75 found pornography arousing. In contrast, Finnish women were significantly less likely to report that they were aroused by pornographic material. Approximately one-third of middle-aged Finnish women aged 45–54 found pornography arousing, whereas less than one-quarter of Finnish women aged 55–64 and 64–75 found it arousing. It remains unclear how well these results could be generalized to other countries’ adult populations, and to what extent these middle-aged and older adults sought pornography from online versus print sources.

Online pornography accounts for a sizeable proportion of Internet revenue (Koerner 2000), and the most popular queries on search engines are for adult material (Miller 2000; Ropelato 2011). More than four million adult Web sites are available online, and America leads worldwide for video production. A new adult video is created every 39 min in the USA. For every four Americans who view online pornography, three are male and one is female. More women visit chat rooms for sexual content than men. Estimates of online viewers suggest that the majority (26%) viewing porn are men aged 35–44, with men aged 45–54 and those aged 55 and older both accounting for 20% of all viewers (Ropelato 2011). Virtually no empirical data is available regarding the numbers of older adult men and women who view online pornography or chat rooms.

It also is unclear what kind of pornography older adult men and women opt to view. For example, it is unclear if older adults tend to view or prefer younger or older adults in their sexually explicit material. Significant cultural differences may also arise. Despite common Western stereotypes that elderly sexuality is negative, distasteful, or otherwise uncouth, Japanese culture is demonstrating a wave of interest in “older adult” film stars. In fact, the fastest growing segment of their adult film industry features elderly adults. For example, a 74-year-old identified only by his screen name Shigeo Tokuda is regarded as a highly successful and sought after porn actor. As touted in Time magazine, Shiego’s production company, Glory Quest, launched a series of “old man” or “grandfather” films starring him in 2004. In his more than 350 films, including “Forbidden Elderly Care,” the 74-year-old is featured having sex with both younger and older women. Shigeo notes that as long as his country’s interest in such “old man” pornography holds, he plans to continue working for at least 6 more years (Toyama 2008). Some women over the age of 70 are now being cast to star “mature woman” Japanese sex films (Sparrow 2008). Conversely, no popular adult film stars in the USA are over the age of 65.

There are potential benefits and harms related to the use of online pornography for older adults. For an older adult who may have difficulty with mobility (e.g., who may be wheelchair or bed bound), who live in predominantly rural areas, or who are embarrassed about going to a public, brick and mortar store to purchase pornography, the privacy afforded by the Internet can be very important. For older adults without a partner, with a partner who is unable to engage in sexual activity, or for older adults who wish to incorporate the viewing pornography into their sexual activity, and for older adults in general, online erotica and pornography can provide helpful fantasies and release. Online pornography comes in a myriad of varieties, including those of interest to straight and LGBT individuals. Of course, problems arise when any person’s use of online or other forms of pornography begin to interfere with their off-line sex life, or someone develops beliefs that healthy sexual activity includes coercion or the persistent objectification of others. The 24-h, 7-day-a-week access of online pornography may make some individuals, including older adults who typically do not work full time outside of the home, more susceptible to some of these problematic situations.

Older adults also can purchase sex toys, vibrators, books, videos, condoms, lingerie, and lubricants from a variety of reputable online merchants, including Amazon.com (the author has no affiliation with this entity), with relative privacy and ease. And, Internet merchants are always open. If an older woman learns from her health care provider and therapist that masturbating with a vibrator could help increase her natural levels of lubrication and ability to orgasm, she may be hesitant to take the bus into town to purchase these items at the local pharmacy or adult bookstore. She may be significantly more likely to purchase one online and have it delivered surreptitiously to her front door. In other words, an older adult’s “nosy neighbor” in their apartment complex or assisted-living facility does not need to know anything about such private but often essential purchases.

The relative anonymity of the Internet also unfortunately allows individuals of all ages, including older adults, to engage more freely in certain illegal or paraphilic sexual activities. Although virtually no empirical prevalence data is available, older adults do engage in illegal sexual activities including exhibitionism and the production and viewing of child pornography. Although federal sentencing guidelines allow older adults to receive shorter or reduced sentences when convicted, especially if alternative forms of punishment could be considered less costly (e.g., giving a shorter prison term if the elderly defendant is seriously medically ill), a recent appeals court decision ruled that in cases of child pornography, age alone does not provide grounds for a reduced sentence. So, elderly adults convicted of possession and use of child pornography can no longer expect leniency due to their advanced age (Arias 2010).

Sexual and Health Education

Adults over 50 report that one of the primary reasons they use the Internet is to obtain medical information (AARP 2010; Nielson 2009), which obviously includes that of sexual health and functioning. In the USA, more adults seek e-health information per day than those who visit their doctor in person (Fox and Rainie 2002). Used in conjunction with advice and discussion with a health care provider or other clinician, the Internet can provide individuals with free, easily accessible sex education as well as vital information about sexual dysfunction, menopause, and prostate and breast cancer, among other health-related topics. Some therapists find it helpful to assign certain Web pages, or online exploration, as homework for their clients if they are struggling with a certain issue. Other therapists ask their clients to print out relevant pages they have been searching, and review them together.

Unfortunately, if an Internet user is surfing the Web alone and is not well educated or familiar with evaluating Web sites for their potential accuracy (e.g., government and university sites are generally reliable sources of information, and end in.gov and.edu, respectively), problems with misinterpreting and receiving incorrect information can easily occur. It could be expected that many older adults are unaware that Wikipedia entries are not necessarily provided or approved by professionals for their accuracy, and that blogs and other Web postings can be generated by anyone, including those who hide or distort their identities and credentials. Simply finding relevant health-related information online can be challenging. Findings suggests that for Internet users looking for health information about cancer, for example, find what they want only 60% of the time, and typically after a lengthy search (Berland et al. 2001).

Even when individuals find appropriate Web sites with accurate medical information, it is important to keep in mind that older adults in the USA possess only basic or below basic levels of health literacy, on average (Kutner et al. 2006). It also is important to note that many people who are literate in standard or the everyday use of English, their health literacy may be significantly lower. Findings show that even when taking community-living older adults’ years of schooling, cognitive ability, number of chronic health conditions, and visual acuity into account, older adults maintain significantly less familiarity with health-related terms and information than younger and middle-aged adults (Baker et al. 2000). Clinicians must keep in mind that their older adult clients may have limited health literacy, and that other clients may not even have access to the Internet. Many older adults turn to adult children or friends, sometimes referred to as warm experts, for assistance in locating and reviewing medical information on the Internet (Wyatt et al. 2005). These warm experts may or may not be able to properly evaluate the validity of the source material (e.g., does it come from a government sponsored Web site or from a personal blog) or provide adequate interpretations or explanations of the online health content itself.

As noted, the Internet can also allow homebound or potentially embarrassed elders the opportunity to purchase various items in relative privacy, including vibrators, condoms, and lubricants. It also remains unclear how many older adults make online purchases for untested and potentially unsafe “sexual enhancement products,” designed to mimic Viagra and other prescription drugs. Other products with questionable efficacy that may be purchased online by older adults include various remedies for hot flashes, night sweats, vaginal dryness, and other symptoms associated with menopause. Some older adults may also have difficulty differentiating between advertising, personal opinions, and professional information on the Internet. Clinicians can provide valuable assistance to older adults who may seek out the assistance of the Internet in finding health and sexually related information.

Issues Related to Divorce and Remarriage

Single heterosexual middle-aged and older adults are more likely to date than marry, consistent with contemporary trends (e.g., Cooney and Dunne 2001). More than one-third of Americans over 50 are divorced, widowed, separated, or have never married, with the majority being divorced (AARP 2003). For older adults over age 65 who lose a spouse, up to one-third become interested in dating within 18 months after becoming single (Carr 2004). This marked growth in the number of older adults who are dating or living together is recognized among savvy businesspeople as a burgeoning market, primarily because the dating behavior of older adults appears more varied than that of younger adults (Schewe and Balazs 1992). Activities for dating among adults over 50 range widely from midnight walks, cooking, bird watching, camping, and attending the opera to square dancing, art classes, movies, mountain biking, and exotic vacations to attending church, visiting children and grandchildren, and making dinner at each other’s homes. For international travel, Elder Hostels offer unique opportunities. The pace at which older adults date and develop emotionally and sexually intimate relationships also appears to be more rapid than among their younger counterparts. Although companionship is cited as the primary reason why older men and women seek romantic partners, studies suggest that up to 90% of these men and women seek love and sexual satisfaction as well (Bulcroft and Bulcroft 1991).

A nationally representative survey of more than 1,000 middle-aged and older adults (AARP 2004) revealed that among individuals aged 50 and older, wives were more likely to initiate divorce proceedings than husbands. Both men and women reported that going through a divorce at midlife was more emotionally devastating than they would expect if they lost their job, and only somewhat less traumatic than what they would expect if their spouse died. Although 45% of the participants indicated that their greatest fear after their divorce was that of being alone, the majority (80%) reported having a positive outlook on their lives. Seventy-five percent of female and 81% of the male respondents reported that they started dating and became involved in a sexually monogamous relationship within 2 years after their divorce.

Among middle-aged Americans, there are three single women available for every two single men (AARP 2003). The greater shortage of single older men among older age cohorts has forced many women over the age of 65 to forgo dating or to engage in a very competitive market. (As noted, some turn to online dating to help broaden their choices.) Women over 65 who do date often receive social prestige in their communities (McElhaney 1992) and tend to be healthier with greater physical mobility. Men over the age of 65 who date tend to be involved in social organizations and to own their own home. It remains unclear whether the women and men over age 65 who date are more psychologically healthy than those who do not, or whether dating itself fosters the development of coping skills and life satisfaction (Bulcroft and Bulcroft 1991).

Despite the apparent benefits of dating in later life, the high ratio of single older women to single older men has important interpersonal implications. One only has to visit a nursing home, retirement complex, or other institution to observe some of the associated dynamics. At one retirement community, an older man complained that his “dance card was always full,” and that he never had a chance to relax with all “of those womenfolk around.” Another older man’s girlfriend lamented, “Every time he goes out to walk the dog, the divorced woman in next unit asks if he would like to come over and have some coffee…I can see that she’s not wearing anything much under her housecoat, for goodness sake…Sometimes it makes me feel very unsure about [our] relationship. I mean, wherever we go, he’s got women fawning all over him.” Another single older woman noted, “If I don’t ask the men to go for coffee, I don’t think they will be asking me. I might as well take a number before they get around to it.” Some of these very literal issues of supply and demand in terms of dating can prove quite challenging, particularly for older single women.

Justine

Dating can be difficult to accomplish, or even define, for some older adults. Justine was a 75-year-old, community-living widow of 8 years. She sought individual therapy for depression and for help in coping with problems related to her adult children. Her depression emerged soon after the death of her husband, with whom she appeared to have a loving, caring relationship. Justine spoke candidly and warmly about their fun times in which they took warm baths together, walked in the rain (with umbrellas so they wouldn’t catch colds), and dancing in the living room to their favorite old records. Justine and her husband also monopolized most of each other’s time; they worked together in a family business and had few outside friends or interests. After 2 months in treatment, Justine had begun to mourn her husband’s loss and to seek out other social contacts in her immediate neighborhood. For the first time, she began to get to know her neighbors. She also took a taxi to the local senior center twice a week and started to make some same-sex friends. Justine also admitted that although she had considered dating other men, her adult son seemed rather opposed to the idea: “You and dad were the perfect couple…How could you ever top that?”

Approximately 1 month later, Justine’s therapist began to worry about her patient’s apparent change in mental status. Justine began to show significant signs of paranoia, and she described hiding things in her own apartment. She also talked about sneaking in and out of the apartment after “making sure that the coast was clear.” Justine began to forget her appointments at the hairdresser, geriatrician, and ultimately with her therapist. Her therapist began to consider dementia or psychotic depression as potential diagnoses for Justine, especially when she claimed that a man was following her to most of her appointments. Justine claimed that she did not forget about them; she just wanted to “go to them alone in peace!”

Because Justine either could not or would not describe anything about the man following her, it was assumed that her mental status was so impaired via delirium that she was recalling prior events improperly, or that she was so depressed that she began to create psychotic delusions in which she was the subject of romantic interest from another man. Her therapist scheduled a neuropsychology examination to rule out dementia and asked Justine’s geriatrician to run additional tests to see if any underlying medical problems could account for her apparent decline in mental status. The results of the neuropsychology testing were ambiguous. Justine was described as having only a mild memory impairment. Justine’s geriatrician felt that she was quite healthy except for her arthritis, and that she was “just imagining things” to feel needed and important.

During her next appointment, Justine lamented that her mystery man had followed her to the hospital. Unwilling to ignore the possibility that Justine was relaying some aspect of truth in her convoluted stories, her therapist called security and asked Justine if she would accompany her to the waiting room to see this man for herself. Justine hesitatingly complied, and when they turned the corner into the waiting area, an older man stood up with his cane and said buoyantly, “Justine, I thought you wouldn’t be done yet! Can I walk you home?” After Justine’s therapist was assured that her patient was in no immediate danger or physical threat from this man, they returned to discuss the issue in their session.

Justine admitted that she had been “keeping secrets…that is my neighbor, Rob…He can’t get enough of me. He follows me everywhere…Sometimes I like it and sometimes I don’t…It’s nice because he helps me put my garbage out when it’s heavy. He shovels my walk when it snows. He brings in my mail for me when it rains and helps me carry my groceries up the stairs. And, sometimes I just like having coffee and talking with him.” Justine began to wring her hands and continued, “Of course, my son and…his wife don’t like it…Rob’s a married man. We, we haven’t really DONE anything. Well, one time he tried to hold my hand and I pulled it away. But his wife sure is steamed. I’m afraid to come out of my house because one day she was waiting on her steps to yell at me and call me names…I haven’t really done anything, don’t you think? I can’t help it if he doesn’t love her anymore, can I? He told me that she doesn’t even bother to take a bath anymore or try to look nice. He gets tired of her nagging and moaning.”

A number of sessions followed in which Justine was able to speak openly about her relationship with Rob, her fears about becoming emotionally involved with another man, her concerns about betraying her departed husband and her son, and her feelings of ambiguity about getting involved with a married man. At one point, Justine considered a restraining order against Rob, but soon realized that she did enjoy his attention, even if it was a bit excessive. For the first time in 8 years, she felt “desirable and pretty…like [she] was courting again.” At the same time, she feared that her relationship with Rob would generate a storm of gossip in the neighborhood in which she “would never be able to make friends, with what all of the other women would think.” Justine’s therapist had to monitor her own countertransference carefully so that she did not interject her own beliefs about marriage and dating into the treatment dynamic.

Ultimately, Justine tried to speak to Rob and his wife about the nature of their relationship. She spelled out that she and Rob “were just friends because she didn’t want to be responsible for breaking up anybody’s marriage.” Rob’s wife remained angry about the relationship, and she forbade Rob to even speak to Justine. For whatever reasons, Rob’s wife tolerated his lack of attention and did not appear to pursue a divorce, separation, or counseling. So, Justine continued their relationship under more clandestine circumstances. She felt that even though Rob had amorous intentions toward her, she did not act on them, making them “just friends, after all.” Justine said she sometimes felt guilty about all of the time they spent together, but she rationalized it as “Rob’s choice to make his wife angry; I didn’t ask him to do any of this.”

In the next few months of therapy, Justine also came to recognize that by being friends with Rob, she had selected a companion who could not, by definition, compete with her dearly beloved husband or upset her son because she “couldn’t marry [him] anyway.” Justine became better able to acknowledge her own needs for love and companionship, and she began to spend more afternoons at the local senior center in hopes of finding a single male companion. She appeared to recognize, on some level, that she wanted a relationship in which she took responsibility for her own actions and in which she did not have to hurt anybody else (i.e., Rob’s wife). She also felt that she had been able to “say good-bye” to her husband, which allowed her to seek a genuine, romantic relationship, rather than a pseudofriendship. She also recognized that her son would have to come to accept her choice in companions; she was the one living alone without a spouse, not him. Like most of the older women in her situation, however, the only single men who went to the senior center already had a steady girlfriend.

Sexuality in Long-Term Relationships

Couples therapy for older adults is essentially similar between older and younger adults. Vital aspects for exploration often include how the couple relates as romantic partners and friends; how they divide responsibility for various chores, tasks, and duties at home; how they experience subjective feelings of love and emotional intimacy; how satisfied they are with sexual expression; to what degree they share activities and leisure time; how they argue, and so on. However, because of age differences, younger therapists may feel somewhat uncomfortable discussing issues related to sexual satisfaction and fidelity. Although the therapist’s tendency may be to discuss those issues more gingerly, they comprise just as important a part of the couple’s clinical assessment as in any work with younger couples. Even more importantly, this may be the first time the members of an older couple have been given the opportunity to openly discuss their sex life, and their satisfaction or dissatisfaction with it.

The developmental challenges associated with aging also can pose some unique problems for older couples. These difficulties may be age or cohort related and can include:

  • Disagreements with adult children over money, wills, finances, power of attorney, and lifestyle choices.

  • Visitation rights with grandchildren, especially if a divorce has introduced stepparents and step-grandparents.

  • The assumption of financial and emotional responsibility for grandchildren; anxiety about financial security, especially if on a fixed income.

  • A move to a new community or care facility.

  • Adjustment to a significant increase in leisure time or the loss of identity as a valued employee through retirement.

  • The loss of friends and family members through illness or geographic relocation.

  • Adjustment to new roles as caregiver for a spouse who may be acutely or chronically ill.

All of these changes and transitions can translate easily into sexual dysfunction or dissatisfaction.

In couple’s therapy with older adults, it also is vital to assume that an older couple’s initial presentation may not be accurate. This is not meant to say that older adults are devious, mischievous, or lacking in insight; many older adults may present initially as a gentle, happy, loving couple because they were socialized to “be on their best behavior” when dealing with a professional. The notion of discussing family problems with outsiders may appear foreign to many older adults, and may result in an initially positive, skewed presentation. In fact, many times couples do not initially seek out couple’s therapy. One member of the pair may present to a clinician with problems of depression, anxiety, or substance abuse, which leads to a trial of couples therapy.

Clinicians should avoid subscribing to stereotypes that frail older adults are “perfect or sweet” because they have stayed together for so long. Even though older couples do tend to remain married, compared to younger couples who are more likely to divorce, older couples are just as likely to have serious problems in their relationships as younger couples. For better or worse, older couples may be more likely to overlook, deny, or tolerate spousal substance abuse or infidelity in their relationship in order to remain married.

The Hortons

Don and Winny, 72 and 67 years old, respectively, arrived together at a treatment team meeting. Winny was excited that she was given permission to take her husband home from the Alzheimer’s unit. Don had been misdiagnosed by a previous practitioner as having Alzheimer’s disease, when in actuality he had a mild case of vascular dementia from sleep apnea. He could be maintained with an alarm monitor and oxygen supply at night, and his dementia was deemed mild enough for him to resume life with his wife at home. Winny beamed, “Oh, we love each other, and get along so well…I can’t wait to take my husband back home. Thank god!” The couple had been married for nearly 47 years and never reported any significant problems in their marriage.

Three weeks later, Winny suddenly came back to the hospital and wanted counseling because she “hated” her husband. She complained that Don was so upset that they had not had sex since he returned home, and she was furious about him “pawing all over me.” When asked if anything else was bothering her, Winny exploded, “He drives me nuts! He wants me to do this, to do that. He tried to change the oil in the lawn tractor and dragged it all over the house and now I have to clean it up. And I have to make his favorite meals, and do the laundry. I am so sick of this!” With Winny’s permission, the intake therapist consulted with members of Don’s previous assessment team, and Don’s original therapist was asked to engage the couple in marital therapy. The therapist’s initial goal was to provide both Winny and Don with more education about Don’s dementia and the changes that might follow in their relationship and household. Both parties also were educated about changes in sexual interest and response related to dementia.

During their second session, Don’s sentiments mirrored those of Winny’s. “The woman makes me crazy. I try to do something, and I guess I don’t do it quite right. She ends up screaming at me for something or other, no matter what I do. I can’t take it anymore. I just want to be with her, you know. I’m her husband and I’m back home now.” The therapist pursued the relationship between Don and Winny, and about the realistic and unrealistic expectations that each held regarding Don’s cognitive abilities, and their mutual concerns about resuming sexual relations after his diagnosis. For some reason, the therapist felt that this discussion was falling on deaf ears, and neither party seemed open to discussing their feelings or fears about Don’s mild dementia. The use of more concrete attempts to engage the couple in developing a homework assignment also appeared to fail.

Reasoning that Don and Winny’s apparent lack of motivation masked some deeper problem, the therapist decided to take a different tact. In order to assess their prior conflicts and coping skills, the therapist asked, “What is the worst thing that has ­happened between the two of you, either lately or in the life of your marriage?” Winny looked at the floor and began to tremble. Don said, “Well, I mean, I don’t know…I guess when I almost ran the mobile home off the road, right? I did have a few to drink, but…” Winny interrupted, “Oh, yeah, you can’t do shit right, can you Don? That’s just it though, and you want me to just laugh and say, ‘OK, that’s all right,’ isn’t it?” Don’s face contorted in anger and he leaned forward in his chair to invade her body space, “Yeah, just like you are always nagging, nagging, nagging! Goddamn woman. Don, do this. Don, do that. Don, don’t touch me, blah, blah, blah, blah, blah.”

The therapist turned to Winny, “What usually happens after Don talks to you like that?” Instead of Winny answering, Don blurted out, “Oh, I tell her, doc. I get right up in her face with my fist and tell her, ‘I’m going to knock you a good one, woman, if you don’t shut the hell up right now! I’m sick of your shit.’ That usually shuts her up pretty good.” Winny sunk in her chair, and Don started with a hmph and sat back confidently in his chair, staring at her. Immediately, the therapist established firm limits and boundaries, stating that violence, or even threats of physical violence, would never be tolerated and were unacceptable no matter what the circumstances. She informed Winny and Don that being upset and angry was a normal part of any couple’s relationship, but that acting on those feelings with physical violence was completely unacceptable.

On further exploration, Winny indicated that Don rarely hit her, but that things “started getting worse” after his dementia was diagnosed and his impulse control had lessened. Dan hated feeling like Winny’s “pathetic, can’t do nothing right, child” instead of her husband, and his anger was expressed more and more often in inappropriate ways. It also appeared that Winny was accepting of Don’s abuse over the years out of a sense of obligation and rationalization; “He never hit me in the face, and he always came home on time, didn’t gamble, paid the bills, and never cheated on me…and I do love him.” The couples therapy took on a radically different direction when it was obvious that their lack of sexual satisfaction was related to more dire, underlying problems.

Even though older adults are from an age cohort that espouses the virtues of marriage and committed relationships, older adults now often elect to live together rather than legalize their relationship through marriage. Older couples may avoid marriage because of pressure from adult children who have concerns about loyalty to deceased parents or about potentially dwindling inheritances, out of respect for their first spouse who they promised to cherish forever, or out of practical concerns regarding income tax problems and estate planning. For those who do have second (or multiple) marriages, problems may arise regarding all of the aforementioned issues. In clinical work with such couples, it becomes vital to identify the intersection between the emotional and practical issues underlying their presenting problem.

The Albertsons

Beverly Albertson, aged 67, was accompanied to the geriatric outpatient clinic by her husband, Dan, aged 71. Their marriage of 13 years was a second marriage (through divorce) for both of them. Beverly came to the clinic seeking therapy for major depression. She had lost interest in leisure activities, in seeing friends, in cooking, in eating, and in sex with her husband. Dan lamented that they once had been “very close,” but that seemed to change about a year ago. Because Beverly and Dan did not appear to be well educated about depression, its origins, or treatment, couples therapy was proposed as an adjunct to Beverly’s individual therapy.

During one couple’s session, it became apparent that Beverly’s depression emerged when she felt that things between them had so badly deteriorated that “it feels like there is no going back.” When asked what she thought had happened, Beverly started to cry. Although Dan did not make any overt attempt to comfort her, he appeared anxious and distressed. Beverly continued, “I just don’t feel special anymore…He doesn’t even touch me anymore. I don’t even want him to touch me anymore. What for, anyway? I don’t count. I don’t matter to him, anyway. I’m just not worth anything to him anymore.” When asked to illustrate a specific time in which she did not feel special, Beverly spent more than 15 min relating a story in which she and Dan went out to eat at a family style pizza pub. Beverly would not even look at her husband when speaking.

Beverly:When he takes me out to eat there, we get the lunch buffet because it’s cheaper. That’s OK, and I can understand that, even though it’s supposed to be like a date, or our special evening out. We don’t have that much money between the two of us. But, he won’t even let me order a soda. I can only get water unless I pay for the soda myself!

Dan:Beverly, we’ve been through this a hundred times! That’s how they make all of their profit! They probably spend ten cents for that soda, and they get over a dollar from me! It’s the principle of the thing. I want her to feel special, but it makes me sick to jack up their profit margin that much. I just can’t do it. We can always get soda at home, so why do you have to have it when we go out?

Beverly:But I want it. Why can’t you just get it for me. It’s one stupid soda!

Dan:Well, it’s one stupid dollar!

Beverly:Well, maybe I’m worth one stupid dollar.

Dan:Yes, but not when it goes in some scumbag, rich guy’s pocket!

The conversation continued and the situation escalated. The therapist allowed for the argument to continue because she wanted to observe their typical pattern of interaction during conflict. Beverly and Dan continued to bicker and yell. They turned physically away from each other, but crossed their arms on their chests in a similar way.

Beverly:Well, the last time [your daughter] came to visit, you sure as hell bought soda when we went out to eat!

Dan:Well, she doesn’t come to visit often from California, and I, I thought it was the right thing to do.

Beverly:The right thing for WHO?

After both parties were instructed to calm down in order to process the interaction, Beverly was able to admit that she always felt as though she played “second fiddle” to Dan’s daughter from his first marriage. She wanted to feel like she was his primary love, and that she did not have to compete to get his attention. More importantly, she was able to admit that she felt that Dan did not love her as much as his daughter. Her lips trembled when she said this, and on seeing her tears, Dan put his arm around his wife, reportedly for the first time in over 3 months.

In a subsequent session, Dan admitted that he felt in constant competition with Beverly’s first husband. He was a wealthy businessman who “allowed” Beverly to maintain a large investment account. Dan admitted he was upset because his pension check could never compare with the kind of money Beverly had in her account. When asked why he called it “her account,” Dan said that he felt slighted that she did not offer to have him as a cosigner in her financial dealings.

On the one hand, Dan said he felt he could understand Beverly’s desire to maintain separate investment, savings, and checking accounts “for her children, for later, if something bad happened,” but that he still felt disdained and overlooked. After all, Beverly did a lot of shopping and bought herself expensive clothes, and Dan lived off of his own, somewhat meager pension. Dan said, “I mean, one dollar is a lot for me, and it is nothing for her…every time she asks me to spend that dollar, it’s like…it’s like I’m just giving it back to her first husband or something.”

In addition, physical intimacy for the Albertsons had become tied to one of the most troublesome aspects of marriage for couples of all ages—money. Specifically, the distribution of valued resources in the marriage appeared tied to perceived competition with spouses from previous marriages, actual responsibilities to children from prior marriages, and the absence of trust between partners. Only after concrete planning and decision making was made about the distribution of money in the marriage, including money that was to be shared and separate, were Beverly and Dan able to resolve issues of trust. Beverly was able to understand that Dan sometimes felt that because he rarely saw his daughter, buying her things was one of the ways he felt he could be connected to her.

Dan became able to understand that since Beverly’s first husband had an affair prior to ending their relationship, she felt“ safer” hoarding her money in case her fears were realized and Dan decided he was going to leave her as well. Once Dan was able to set aside his competitive urges, to empathize with Beverly’s fears, and to let her know that he was a different man than her first husband, Beverly decided to share some of her money in a joint account, and the couple began to feel secure enough in their relationship to engage in meaningful, satisfying sexual relations. In a more symbolic display of their ability to trust and give pleasure to one another, they also began to order two sodas and pay for dinner out of their joint account on their excursions to the local pizza parlor. More importantly, if the couple’s therapist had pursued issues related only to their sexual dissatisfaction, the Albertsons’ true, underlying problems related to their prior marriages would never have emerged.

Sexuality at the End of Life

For most individuals, thoughts about the end of life, hospice, and palliative care typically include pain, suffering, and sadness. Other associations to hospice may include hospital beds, oxygen masks, the administration of pain medication, and soft music and prayers. Although some individuals in hospice may not have the need or ability to engage in intercourse per se, the need and desire for other expressions of sexuality including holding, touching, fondling, kissing, massaging, and caressing may remain strong. For many patients, physical contact with a loved one can significantly improve their quality of life (Cort et al. 2004). Unfortunately, most people regard any expression of sexuality at the end of life as taboo, and many social workers, psychologists, nurses, physicians, and other health care providers fail to address hospice patients’ sexuality (Katz 2011; Kutner et al. 2001).

Benefits

Sexuality obviously includes a variety of activities, ranging from physical activities that include others (e.g., intercourse, fondling, hugging, kissing, holding hands, cuddling) to those that are often solitary in nature (e.g., masturbation; bathing). Sexuality can also include nonphysical manifestations in the form of sex talk (or texting) with others, private thoughts, dreams, and fantasies, and the viewing of pornography either alone or with others. In terms of palliative and end-of-life care, adopting the broadest view of sexuality and sexual expression becomes essential. Clinicians can help dispel general societal myths that “sexuality equals sex,” which only limit the ability of patients and their partners and health care providers to receive vital assistance (Redelman 2008).

A primary goal in palliative care is to improve patients’ quality of life (Richards and Ramirez 1997). In one of the few empirical studies to examine hospice patients’ sexuality, more than half of the 348 patients assessed, with an average age of 78 years, experienced significant problems with pain, lack of appetite, fatigue, drowsiness, concentration, and feelings of sadness. More than 60% of the patients assessed experienced problems with their sexual interest and activity, and the social workers in the study treating them reported that they felt unprepared to deal with their sexual problems (Kutner et al. 2001). In other words, nearly half of those older adult patients observed did sustain interest in sexual activity through the end of life. Other empirical studies suggest that terminally ill women and men desire sexual or physical contact with their partners, but feel too ashamed or “abnormal” to make their wishes known (Cort et al. 2004). It is as though these patients internalized general societal beliefs that sexuality is a privilege that belongs only to those who are healthy and young.

The benefits of sexual expression and intimacy in hospice and palliative care cannot be understated (Redelman 2008). Many dying individuals want to strengthen their relationships with partners and loved one, and sexual expression and physical intimacy can certainly be a significant part of that process (Singer et al. 1999). The simple act of physical touch or contact can be associated with significant changes in autonomic nervous system activity. The act of pleasant physical touch can release various neurotransmitters, leading to feelings of warmth and muscle relaxation (Weeks 2002). Participation in sexual activity including masturbation also has been associated with pain relief (Komisaruk and Whipple 1995) and improved quality of sleep (Weeks, and James 1998). When hospice patients’ needs for sexual expression are not met, whether that means not being able to hold hands or to have intercourse, the results can be quite negative, including depression and significant declines in self-esteem (Leviton 1978).

Barriers to Expression

Significant barriers exist in relation to the expression of sexuality in hospice and palliative care. Scars from surgical procedures and even removal of various body parts including breasts and testicles often lead to feelings of embarrassment, loss, anger, and resentment (Rabow et al. 2004). The resulting declines in self-esteem and negative feelings about one’s body image certainly do not bode well for the expression of sexuality even under optimal circumstances (Cagle and Bolte 2009). Concerns and issues related to pain, fatigue, and lack of privacy also prohibit participation in many sexual activities. Many hospice settings do not offer double beds, and many staff members come and go without knocking. Even when hospice services are offered in a patient’s own home, many patients are moved to a single hospital bed, often on the first floor in a living room to provide more room for staff. This arrangement may have certain benefits, but the patient’s privacy obviously becomes severely limited.

Even within the professional literature there appears to exist a dual stereotype or taboo in which sexuality among older adults as well as sexuality among the terminally ill becomes suspect. In a 2008 article appearing in the American Journal of Hospice and Palliative Medicine the author notes, “Many dying individuals will be in the older age group where the sexual needs between the couple may have found a nongenital/physical sexual expression, where sensuality expressed by hugging and kissing has become the norm…This may allow for an easier transition to the socially/institutionally acceptable interaction in [hospice care]…this may contrast sharply in a younger couple where an active sexual relationship is lost suddenly [leading to] anger…resentment…and frustration” (Redelman, p. 366). From this passage, it is as though only young adults have an active sex life and could be expected or entitled to mourn the loss of their sexuality. When professionals themselves discount the clear empirical evidence that older adults in intimate relationships can and do engage in sexual activity including penetrative intercourse, oral sex, genital fondling, and other forms of physical intimacy throughout their lives (e.g., Fisher, 2010), it becomes clear that there are more than institutional barriers to sexual expression within the context of hospice.

The literature is rife with portrayals of clinicians and health care providers who fail to recognize, acknowledge, and discuss issues related to sexuality with their end-of-life patients (e.g., Lemieux et al. 2004; Redelman 2008). One of the only available empirical studies of health care professionals’ attitudes toward the discussion of sexuality with their patients in palliative care suggests that patient sexuality is medicalized, which limits discussions of sexuality to fertility, menopause, and erectile dysfunction (Hordern and Street 2007). This overreliance upon medical terms and diagnostic criteria also appears to allow health care providers to emotionally distance themselves from thinking about their patients as sexual beings.

The social workers, nurses, and physicians in Hordern and Street’s study (2007) also avoided the topic by viewing their patients as asexual (especially if they were older), by assuming that someone else on the treatment team had already discussed sexual issues, by fearing that such a discussion would offend patients from various ethnic and religious backgrounds (e.g., Muslim) and by believing that they simply could talk about sexuality without becoming too personally vulnerable. Those clinicians who did attempt to broach the topic often tried to use humor to dispel their discomfort with the topic. Other researchers suggest that time constraints and fears that other professionals will regard discussions of sexuality with dying patients as inappropriate or over-attentive provide additional barriers to assessment (Cort et al. 2004). With pervasive social taboos about the open discussion of sexuality, aging, and death and dying, coupled with the generally limited amount of training and education available to clinicians about these topics, these findings sadly do not appear that surprising.

Talking with Patients and Clients

Although clinicians tend to avoid discussing sexuality at the end of life, individuals undergoing hospice care typically report that they want information about sexual functioning (Ananth et al. 2003). Patients also expect that their health care providers will broach the subject first (Gamel et al. 1993). The National Hospice and Palliative Care Organization regards an assessment of patient sexuality as a core competency for those working with individuals at the end of life, but their national curriculum provides no such detailed instructions (Hay and Johnson 2001). Fortunately, a number of researchers and clinicians offer outstanding recommendations about how to communicate more effectively with hospice and palliative care patients to address sexual issues. Hordern and Street (2007) offer some “opening lines” to help discuss the topic. Normalizing the topic is essential, as is placing control of the discussion with the patient or client.

  • Many of the patients and clients I see express concerns about how treatment may affect their sex lives. How has this been for you?

  • How has this experience affected intimate or sexual aspects of your life?

  • Has your role as parent, partner, spouse, or intimate friend changed since you were diagnosed or treated?

  • Is this the right time and place to discuss these issues further?

  • Am I the right person for you to discuss these issues?

  • In my experience, many people find that this disease or treatment has made a major impact upon their sexual activity or intimacy.

  • How can I best provide you with information, support, or practical strategies to help you?

Taking a sexual history is essential (Stausmire 2004) regardless of a patient’s marital status. Assumptions that the patient is heterosexual (or even male or female versus transgender) also should be avoided. For example, it is important to inquire about intimate partners rather than husbands or wives. Consideration of a couple’s previous level of sexual and emotional functioning is essential (Cort et al. 2004), and will likely be obtained from the sexual history. Additional considerations for clinicians when speaking with patients about sexuality at the end of life include having a warm, empathic, and open attitude, providing information that dispels myths and misconceptions (e.g., many people who are terminally ill have sexual feelings and desires; radiation cannot be passed to a partner through sexual contact), speaking without technical jargon and terminology, using open-ended questions, and respecting the values of the patient (Cagle and Bolte 2009). Reinforcing the confidential nature of these discussions also remains essential (Cort et al. 2004).

It also is critically important to ask about permission to speak with significant others because many partners of those in hospice or palliative care are afraid to physically interact with their loved one out of fear of causing them discomfort, pain, or injury (Stausmire 2004). Giving patients and their partners time to come up with questions, or to be able to write them down and give them to the clinician can help provide an increased sense of confidence and control. It also is important to note that some patients may seek closeness with their partner, in a variety of forms, whereas the partner may wish to emotionally (and physically) distance themselves to avoid facing feelings of loss and abandonment (Redelman 2008). Working with partners individually and as a couple can provide a wealth of information that can ultimately benefit patients and their relationships.

Practical Suggestions

A number of practical recommendations also can be offered in work with patients or clients in palliative care who wish to engage in sexual activity, either alone or with a partner. In addition to the emotional challenges that present themselves in the face of illness at the end of life, clear medical, physical, and institutional challenges also present themselves. For example, indwelling catheters, IVs, and oxygen masks can pose clear obstacles for patients who wish to engage in sexual activity whether it involves intercourse to holding hands and cuddling. Psychologists, social workers, professional counselors, chaplains, and other mental health providers can work as part of an interdisciplinary team to help provide this assistance. For example (Cagle and Bolte 2009; Cort et al. 2004; Katz 2011; Lemieux et al. 2004; Stausmire 2004):

  • Give patients and couples private time. Provide the use of “do not disturb” signs to patients, and enforce rules that staff and caregivers knock and receive permission before entering a patient’s room.

  • When possible, remove extra medical devices and equipment when couples wish to engage in sexual activity to make the setting feel less clinical. Encourage patients and their partners to bring along things from home such as pillowcases, photos, and music.

  • If a patient wants help with grooming, provide assistance or schedule visits with hairdressers and manicurists.

  • Consider the importance of oral care, particularly if a patient expresses a desire to engage in kissing or other oral activities with their partner.

  • If a patient experiences fatigue primarily in the afternoon or evening, consider suggesting that sexual activity take place in the morning to take advantage of increased energy.

  • For patients who have surgical scars or who experienced a disfiguring surgical procedure, normalizing negative feelings is essential. For example, “After a mastectomy it is not unusual for women to report higher levels of dissatisfaction with their body image” (Cagle and Bolte 2009, p. 229). Some women may elect to wear a camisole or bra with an insert if that allows her to feel more attractive or to focus more upon her own sensual experience. Similarly, if a man is concerned about scars or any surgical change to his genitals, normalizing any negative feelings and offering suggestions for wearing underwear or shorts during sexual activity may provide similar relief.

  • Discuss alternative positions for sexual activity, including those that place the patient on their side or back, supported by pillows.

  • If a partner is afraid of causing pain by touching, consider bathing and other sensual activities involving massage, stroking, hugging, and applying body lotion.

  • If possible, provide patients with a double bed so that their partner can lie next to them. Sometimes a lounge chair can be placed next to a hospital bed in the upright position so that partners can sit next to each other and touch and hold hands.

  • Consider that some patients do not want to relate to their partners as caregivers per se, or that they may feel embarrassed or humiliated by engaging in certain activities in front of their partner. For example, some patients do not want their partners to be involved in certain activities of daily living and personal care including dressing or toileting.

  • Consider timing the administration of pain medication to coincide with sexual activities.

  • For patients who are short of breath, use of an inhaler or bronchodilator before sexual activity, if prescribed, can be helpful. Sitting upright or propped up with pillows can help make breathing easier.

Working with patients at the end of life is obviously challenging. However, clinicians can give patients and their partners the gift and freedom of communicating openly about sexual issues and concerns, rather than have them suffer in silence (Katz 2005). Because hospice and palliative care typically involves an interdisciplinary team, it is important that mental health providers such as psychologists, social workers, professional counselors, and chaplains take the lead in discussing sexual issues and concerns, as research suggests that most clinicians avoid the ­discussion or assume that other team members have already broached the subject. It also is important to remember that for those partners left behind upon the death of a hospice patient, the mourning process continues just as their sexuality and sexual needs continue. Sexuality remains a fundamental human need, even at the end of life, and psychologists and other mental health providers can play a lead role in ensuring its continuing value.

The Medicalization of Sexuality and Aging

Another challenge that can be expected within the context of sexuality and aging is the medicalization of sexuality. In other words, the medical model is likely to take center stage in the assessment and treatment of sexual dissatisfaction and dysfunction among aging adults. In our current culture of fast food, fast transit, and instant messaging, individuals often want a “quick fix,” typically in pill form. They may lean exclusively on medical treatments to remedy sexual dissatisfaction that actually stems from underlying psychological problems such as marital discord, distortions in body image, or emotional difficulties in adjusting to disability. Simultaneously, however, medical knowledge and expertise play an essential role in helping middle-aged and older adults remedy many sexual problems. Mental health professionals need to become generally aware of these treatment options and make appropriate referrals. For example, all male clients concerned about ED should be referred to a urologist or geriatrician to rule out underlying medical problems. Accordingly, mental health providers will necessarily, if not preferably, find themselves enmeshed in this medical culture and will probably find themselves working within the context of interdisciplinary treatment teams.

As noted, the medicalization of sexuality offers significant challenges. Many clients and some medical professionals adopt a unidimensional approach to sexuality and aging, in which psychological issues and behavioral treatments (e.g., sensate focus; biofeedback) are either devalued or dismissed for the sake of a quick fix (e.g., a pill). Physicians typically command higher fees than psychologists and other mental health providers, and clients and physicians may see this difference as representative of the increased value or efficacy of medical treatment. Managed care companies, which tend to devalue psychological treatments, are more likely to pay for a visit to a geriatrician or urologist than to a psychologist. Clients who rely on insurance may be afraid to seek out treatment when they learn that their own insurance company does not value sexuality within the context of aging (e.g., certain managed care companies report that they will not pay for Viagra because “sex is not medically necessary” for older men).

Summary

With the aging of the baby boomers, American society will place increasing demands upon clinicians to be trained in both issues related to aging and sexuality when, unfortunately, the field of mental health is already behind in providing appropriate numbers of professionals trained in gerontology. Fortunately, with the American Psychological Association’s newly approved recognition of geropsychology as a professional specialization, a variety of professional organizations are now available to clinicians seeking related training and education. The medicalization of sexuality and aging is likely to continue, and clinicians will likely find themselves working within interdisciplinary settings. Relatively unexplored areas such as sexuality among minority group and LGBT elders, HIV and aging, sexual consent capacity, and sexuality in institutional settings and at the end of life require increased clinical and research attention. Mental health professionals are in a unique position to shape the future of sexuality and aging, and the education of both clients and clinicians represents the first step in this meaningful and distinguished process.