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Introduction

Human advancement has allowed people to live longer and healthier lives the world over—and the numbers say it all. 2006 recorded almost 500 million people over the age of 65 worldwide, and this number is expected to double by 2030 [1]. This means that seniors will comprise one out of eight people on earth. In addition, developing countries will see a rapid jump in their senior population by 2030, with some estimates as high as 140% increase.

While these numbers are encouraging from a social, medical, and economic standpoint, they also bring forth monumental challenges. An aging population strains existing support models such as social and pension systems, affecting everything from economic growth and trade to disease patterns and migration. It challenges the fundamental assumptions of growing older.

Other important issues representing the aging population pertain to sexuality and various determinates [2], which are often neglected. In fact, even the World Health Organization (WHO) acknowledges that reproduction and sexuality are fundamental components to the health and well-being of human beings [2]. Sexual health is defined by the WHO as a state of mental, physical, as well as social well-being. It requires a positive and dignified approach to matters such as sexuality, relationships, as well as safe and pleasurable sexual experiences. Sexual health is determined based on complex interactions between various domains such as the sexual desire, frequency of intercourse, orgasm and/or ejaculation, erectile function, early-morning erections, and overall satisfaction with an individual’s general health as well as sex life. These domains are defined by the fitness levels of the individual as well as their partner [2].

A clear understanding of sexuality becomes increasingly important as beliefs surrounding aging, gender, sexuality, and personal happiness continue to transform as individuals live longer and healthier. Owing to this, the interest in studying and characterizing modifications in the relationship between sexual health and aging has increased significantly.

Changes in the Sexual Response Cycle

As defined by Masters and Johnson [3], all stages of an individual’s sexual response cycle are influenced by age and its associated factors. In addition, there is no conclusive scientific evidence to prove that sexual dysfunction is inevitable with increasing age of both men and women, who are otherwise physiologically and psychologically healthy.

Sexual response cycle in aging men: With increasing age, men tend to experience age-related changes in the excitement stage of the sexual cycle such as a steady decline in β-adrenergic receptors as well as cholinergic receptors. This consequently leads to an increased activity in α-adrenergic receptors, and in turn interferes with relaxation of the corporal smooth muscles that is necessary to initiate and maintain erectile response [4]. Furthermore, an increase in the connective tissue deposits can decrease distending capacity of the penis. These factors further lead to decreased elasticity in the corpora cavernosa, making it difficult to achieve and maintain normal erections [4].

Common physiological changes in aging men include:

  • Atrophic changes in the sexual organs

  • Decreased testosterone levels

  • Delay in achieving erection

  • Poor erection function and quality

  • Failure to sustain erection

  • Reduced desire due to reduced hormone levels

As compared to young men who can achieve erection in a couple of seconds, older men may require several minutes to do the same [4]. Hence, partners might have to help in actively facilitating an erectile response through intense stimulation before intromission. With aging, penile sensitivity and rigidity also decline gradually [4]. Penile erection may be satisfactory for intromission but couples may need to supplement intercourse with other forms of stimulation (manual or oral) or experiment with different coital positions to sustain arousal and mood.

The plateau stage is prolonged with age, whereas the duration of orgasm declines. Further, the duration of the refractory period is also significantly increased. With respect to the postorgasmic refractory period, older men may require several days to recover when compared to younger men. This is fundamentally because with increasing age, the restoration of ionic neurotransmitters requires a longer time [4].

Sexual response cycle in aging women: The female sexual response cycle sees similar changes as with men. The onset of lubrication in the vagina takes a couple of seconds in younger women versus a few minutes in older menopausal women. The quantity may also be reduced [4]. This vaginal dryness is usually caused by a decreased vasocongestion and lubrication in the vagina, leading to painful coitus. As with men, the plateau phase of the sexual response cycle is delayed in older women. However, orgasmic response in women is not particularly affected by age, as several women report multiorgasmic capabilities [4].

Some of the most common physiological changes in aging women include:

  • Declining secretion of estrogen after menopause

  • Decrease in vaginal lubrication

  • Shrinking of cervix and uterus

  • Decreased elasticity in breast tissue

  • Decreased breast dimensions

  • Atrophy in the vaginal canal

  • Decrease in length and width of the vagina

Psychological Impact on Men and Women

Apart from physiological changes, another prevailing factor that should be considered in the equation is ageism—where social beliefs and attitudes deem sexual behavior in seniors to be inappropriate or even abnormal. Older people also find it difficult to come to terms with their declining attractiveness, physical attributes, and sexual potency. As a result, their sexual health is affected by negative attitudes towards sexuality, as well as social constraints caused by disturbed relationships, physical infirmities, economic worries, and psychological problems [5].

A study conducted in Finland [6]to gauge the attitudes of sexuality and satisfaction of these needs concurs with the statements above. Fifty residents in a nursing home were interviewed to gain a better understanding of basic human needs, particularly sexual, as well as need satisfaction in seniors. More than half the participants did not consider it appropriate for older people to enjoy an active sex life [6]. Twenty-five percent felt that addressing sexual needs and desires was shameful or sinful [6]. Less than 25% of the participants were willing to speak to the nursing home staff regarding sexual matters [6].

Sexual Behavior in the Aging

Epidemiological studies: comparisons between men and women: The Masters and Johnson report [3], supplemented by multiple other studies, suggests that older men and women remain sexually active throughout their lives. They did not find an upper age limit for healthy sexual function. However, some evidence shows that with increasing age the frequency of sexual activity diminishes.

Between 2001 and 2002, the Global Study of Sexual Attitudes and Behaviors (GSSAB) interviewed 27,000 participants across 29 countries. This group included men and women between the ages of 40 and 80 years. Twenty-one percent of women and almost half of men aged between 70 and 80 years reported having intercourse in the past year of the interview [7]. Within the age group of 40–49 years, this number included 93% of men and 88% of women [7]. An interesting find in the study indicated that 17% and 23% of men and women, respectively, said that “elderly people did not want sex” [7]. However, 68% of men and 60% of women were also in favor of seniors seeking treatment to enjoy sexual pleasure [7].

Similarly, the National Social Life, Health, and Aging Project (NSHAP) worked with 3005 men and women aged between 57 and 85 across the USA. This national probability sample reported that while men were more likely to remain sexually active than women across all ages, they did not discuss their problems with doctors. The study also found that the most common sexual dysfunctions in men included erectile dysfunction, lack of interest, and inability to climax [8]. The prevalence of these conditions increased with age, with the exception of premature ejaculation (PE)—a condition that affected 28% of all men and was more common in younger age groups [8]. On the other hand, common sexual problems among women included low sex drive, inadequate vaginal lubrication, and inability to climax [8].

A case-control analysis by Syme et al. revealed that 62.4% of subjects between 63 and 67 years had sex once a month or less frequently, to once or more a day. In general, men were found to be more sexually active than women. However, there have been fewer differences in the sexual behaviors of men and women in more recent studies in comparison to those in the past.

Studies specific to men: Helgason et al. studied sexual functions in 319 randomly selected Swedish men ranging from the ages of 50 to 80 years. Seventy-one percent of the group were sexually active with many men reporting adequate erections during sexual intercourse [9]. However, the rate of poor maintenance was equally high, adding up to 72% [9].

A population-based study conducted in Krimpen assessed 1688 Dutch men to study the prevalence of ED. Three percent of men ranging from 50 to 54 years were diagnosed with ED, a number that rose to 26% in men between 70 and 78 years [10]. A related Health in Men Study indicated that while 49% of the participants reported ED, only 3.2% claimed to have unpleasurable sex.

Studies specific to women: Validated scales are not frequently used in women-centric studies, limiting the accuracy with which sexual function and dysfunction can be measured [11]. Further, factors such as limited age ranges, low rate of response, as well as restrictive inclusion criteria affected the limit of generalizability of these studies. Similar to men, evidence indicated that sexual functions of women decreased with age, beginning from the late 20s to late 30s [11]. In particular, desire as well as frequency of orgasm and sexual intercourse declined sharply with advancing age.

It is also important to note that studies that utilized a broader and more inclusive definition of sexual activity (i.e., including not just sexual intercourse but any activity that involves sexual arousal) showed that despite the negative correlation between sexual activity and age, senior women remained sexually active [11].

Determinates of Sexual Behavior Modification with Aging

Sexual performance is impaired with aging owing to the interference of vascular, endocrine, and neurological functions. That’s not all; other relational and psychological factors such as the partner’s age and sexual function, length of the relationship, and their emotional response to the partner also play an important role in the process. In a study on 2187 men, relational, intrapsychic, and organic factors could independently predict impaired erections [2].

Comorbidities in Men

Cardiovascular diseases: Studies suggest that CV and ED-related diseases should be considered as different manifestations of underlying vascular pathology. In fact, ED should be treated as the first sign of forthcoming coronary artery disease (CAD). It also serves as an efficient predictor of silent CAD in diabetics independent of ED severity and glycometabolic control.

Obesity: Major epidemiological investigations such as PROCAM, NHANES, and Framingham have proved that obesity is an independent factor that increases mortality in men, caused largely due to coronary atherosclerosis and other cardiovascular diseases. The chances of developing ED are 2.5 times higher in obese men than those of healthy and normal weight.

Diabetes mellitus: Some studies indicate that men over the age of 66 years with type 2 diabetes have a 49% chance of developing ED. Some common complications associated with diabetes mellitus include retrograde ejaculation as well as anejaculation.

Comorbidities in Women

Cardiovascular diseases: An observational study conducted by the Women’s Health Initiative depicted that dissatisfaction with sexual activity at baseline had a 44% higher risk of developing peripheral artery disease [12]. The longitudinal data also showed similar risks of developing myocardial infarction, coronary vascularization, or stroke even after controlling for smoking status [12].

Obesity: One hundred and six obese women with a median BMI of 44.5, who also underwent bariatric surgery, were analyzed under a prospective cohort study. Postsurgery, these women showed significant improvement in sexual activity across most reproductive hormones of sexual interest as well as psychosocial status [13]. This shows that obesity in itself is predictive of poor sexual function along with increasing age.

Relational Components

Couples of all ages face similar causes of sexual dissatisfaction, ranging from commitment issues, problems with communication and intimacy, and marital conflicts to an imbalance in relationships, boredom, and a mismatch in sexual desire [4]. In elderly couples, these factors are sometimes amplified by resentment and anger built over the years, even decades of the relationship. In addition, feelings of resignation and entrapment contribute further to sexual dissatisfaction, particularly if leaving the relationship is no longer an option.

Intrapsychic Components

The intrapsychic components that contribute towards sexual dissatisfaction in younger men are largely associated with problems in the work environment. However in older men, these components comprise psychosocial stresses such as loss of job, death of a partner, deteriorating support systems, worsening of social status, and other family problems related to health or finance [14]. These radical life changes may affect sexual performance and increase the likelihood of developing anxiety and/or depression, especially in older men. In addition, depressive symptoms and drugs used for other comorbid medical conditions may impair multiple aspects of sexual function in men such as erection, sexual desire, as well as ejaculatory reflex. Repetitive experiences of such failure can compound the issue and amplify performance anxiety, and personal vulnerability and distress [14].

Sexual Satisfaction and Aging

Much of the scientific literature evaluated and focussed on the various pathophysiological processes in aging that can affect sexual function and activity. There are limited studies on other emotional and psychological factors. In addition to physical benefits, sexual satisfaction can enhance the overall well-being of an individual and strengthen intimate relationships and marriages [15]. Sexual satisfaction is the result of these factors interacting on different levels—individual, relationship, and culture [15]. Physical changes as well as illnesses associated with aging can reduce physiological response and sexual desire. However, it is also important to emphasize and understand how sexual satisfaction is influenced by individual cultural norms embedded in individuals [15].

Conclusion

Aging is in general associated with a reduced frequency of sexual activity. While epidemiological evidence suggests that sexuality remains an important issue for aging men and women, cultural influences and stereotypes in our communities make it difficult for doctors and aged patients to communicate honestly. Some doctors still view sexual dysfunction as a natural biological aspect of aging instead of a medical issue. As a result, older patients hesitate to discuss sexuality and sexual health with their primary care physicians.

This lack of open discussion leads to sexual issues not being addressed, further resulting in social withdrawal, depression, and even delayed diagnosis of underlying conditions. These misconceptions and negative attitudes can only be addressed with proper education and encouragement from healthcare professionals on age-related changes to sexuality, as well as advice on meaningful sexual relations.