SEX, INTIMACY, AND THE AGIN G PROCESS
HELEN S. KAPLAN, M .D., Ph.D.*
The loss of sexuality is not an inevitable aspect of aging, and the majority of healthy people remain sexually active on a regular basis until advanced old age. However, the aging process does bring with it certain changes in the physiology of the male and the female sexual response, and these along with a number o f medical problems that be come more prevalent in the mature years, play a significant role in the pathogenesis of the sexual disorders of the eldèrly. The typical patient over 50 has only a partial degree of biological impairment, which has, however, been escalated into a total sexual disability by a variety of cultural, intra psychic, and relationship stressors. Fortunately, these problems are frequently amenable to an integrated psychodynamically oriented sex therapy approach that empha sizes the improvement of the couple’s intimacy, and the expansion of their sexual flexibility. The information about age-related sexual disorders as well as the concepts and treatment approaches that are presented in this article are the product o f our observations o f over 400 patients with sexual complaints who were 50 years or older, over the past 10 years.1"* Our method of evaluating couples with sexual dysfunc tions includes, in addition to the customary sexual, psychiatric, and medical histories and examinations, a highly detailed investi gation o f their current sexual status and experiences and behaviors (Kaplan, 1983). This has enabled us to compare the adaptive be haviors and constructive interactions o f couples who manage to ♦Clinical Professor of Psychiatry and Director of the Human Sexuality Pro gram, The New York Hospital-Comell Medical Center. This article developed from a talk at the American Academy of Psychoanaly sis, October 1,1988, New York City. - **The age range of our population was 50-92, and included single patients as well as couples, wherein one or both partners were in that age group. The patients were seen by myself and my associates at the Human Sexuality Program of the New York Hospital-Comell Medical Center, and also in our private practice group. " Journal o f The American Academy o f Psychoanalysis, 18(2),'185-205, 1990 © 1990 The American Academy o f Psychoanalysis
186 KAPLAN
function and to enjoy sex until advanced old age with the maladap tive behaviors and the destructive interactions of those who devel op sexual dysfunctions or who cease having sex altogether after their menopausal years. This rich clinical experience has yielded many valuable insights into the pathogenesis o f sexual disorders in the elderly, and has clarified the important role that intimacy plays in a couple’s healthy adaptation to the aging process. SEX AND THE AGING PROCESS There is a widely held belief in our society, which is shared by the general public and health professionals alike, that sex is among the first biological functions to fall prey to the aging process. But this is a myth. Actually, sexuality is among the last o f our faculties to decline with maturity. From an embryological perspective, we age “from the outside in,” so to speak. We begin life as three tiny concentric tubes, from which the different organs develop. The outer or exodermal layer of the embryo develops into skin, the sensory organs, and the nervous system, and these are the tissues that begin to show agerelated changes first. Thus in our 40s, our skin begins to wrinkle, we start using reading glasses, and we find ourselves having trouble remembering the names of people we meet at cocktail parties and seminars. Sometime later, the middle, or mesodermal tissues, begin to show senescence. The embryologic middle layer produces our mus cles, bones, connective tissue, and blood vessels, and in the 50s, cardiovascular diseases and musculoskeletal problems such as ar thritis and the rheumatic disorders make their appearance. Breathing, eating, and sex, the functions o f the organ? that are derived from the innermost tube or endodermal layer, endure the longest. So, most of us are still sexually active long after we have begun to use hearing aids and eyeglasses, and some of my elderly - patients are still enjoying good sex, although they cannot always remember the name of their partner. SEXUAL ACTIVITY AND AGING s
During the past 40 years, the sexual behaviors of thousands o f American men and women between the ages of 50 and 100 have been scientifically investigated (Kinsey et al., 1948, 1953; Masters and Johnson, 1966, 1970; Palmore, 1970, 1974; Starr and Weiner,
SEX, INTIMACY, AND AGING 187
1981). The results of these studies are remarkable in their consen sus: Without exception, each investigator found that, providing they are in good health, the great majority of people remain sexu ally functional and active on a regular basis until virtually the end of life. Or, to put it more succinctly, 70% of healthy 70 year olds remain sexually active, and are having sex at least once a week, and typically more often than that. (See Figure 1.) These findings are entirely consistent with our own clinical experience. AGE-RELATED CHANGES IN SEXUAL FUNCTIONING I do not mean to imply that we retain our full youthful sekuality all our lives. There are, of course, certain inevitable age-related changes in sexual physiology, and these affect men and women differently. More specifically, male sexuality peaks sharply at around 17 and then gradually declines, whereas women do not reach their full sexual potential until their late 30s or early 40s, and then they slow down to a lesser degree than men. Moreover, the aging process does not result in general sexual decline, but has a specific and different impact on each of the three phases of the human sexual response cycle. (See Figures 2 and 3.) Below is a brief summary of those age-related biological changes that are of special clinical significance because of their role in the pathogene sis of the sexual complaints of the elderly. Orgasm Orgasm in males and females consists of the reflex rhythmic contractions of certain genital muscles (the ischiocavernosii and the bulbocavernosii muscles), which are normally perceived as highly pleasurable. In the male, these muscles are located at the base of the penis, and their 0.9-per-second spasms eject semen through the urethra out of the tip of the penis. Analogous 0.9-persecond contractions of the same genital muscles, which in females are located around the vaginal introitus, produce the sensations of female orgasm (Kaplan, 1974). ♦The results of a European and an Israeli study of sex and aging are strikingly similar to the U.S. findings, namely that the great majority of healthy people remain sexually functional and active on a regular basis into advanced old age (Tbradella and Boscia, 1985; Weitzman and Hart, 1987).
S tu dy
Year
1. Kinsey Reports
19481953
N
212 O' 152 9
A ge Range
51-90 51-80
70% of couples are sexually active at age 70 on a regular basis. The average frequen cy over 70 is 0.3 times a week.
50-90
Found men and women in all age groups who remain sexually active on a regular basis.
'E 364
2.
Masters and Johnson
19661970
150 0 * 212 9
E 362 3. Duke University Longitudinal Study
19531965
o*+9
1968present
o*+9
250 60-90
502 45-69
E 752 4.
1981
Starr- Weiner R eport on Sex a n d Sexuality in the M ature Years
280 0 * 520 9
60-91
E 800 -
5. Consumer Union Survey: Love, Sex,
1984
4,200
Figure 1.
188
1984present
6,478
a+9
70% of physically healthy couples have regular intercourse at the age of 68. In some cases, the frequency of sexual intercourse increases. 80% of total sample (O’ & 9 ) are sexually active. 50% have sex on a regular basis. Of these, 50% have intercourse once a week or more often.
50-93
79% of men, and 65% of women aged 70-91 are sexually active on a regular basis. 58% O* and 50% 9 have sex every week.
50-93
The majority of physically healthy men and women remain sexually active on a regular basis into the seventh decade and beyond.
o*+9
an d A gin g
All studies combined
O u tcom e
Sex and the aging process: Summary o f recent studies.
SEX, INTIMACY, AND AGING 189
Male
Phase I Orgasm Genital Muscle Spasm
A. Emission Contraction of internal muscles
B. Ejaculation
Female A. No emission B. Q orgasm Perineal muscle contractions
Perineal muscle II Excitement Genital Vasocongestion III Desire Activation of brain sex centers
Erection
Lubrication—Swelling
High blood pressure system in penis
Diffuse genital vaso congestion
Sexual Passion or Libido
'
Activation of specific CNS areas—mediated by tes tosterone in both genders
Figure 2. The three phases o f the sexual response cycle. In males, the refractory period increases substantially with age. The refractory period is that length o f time that must elapse after a man has ejaculated, before he can be stimulated to another climax (when he is refractory to further sexual stimulation). This interval lengthens from just a few minutes at the age of 17, to as much as 48 hours by the age of 70. In contrast, women, probably because they do not ejaculate, do not have a significant refractory period at any age, and remain physically capable of experiencing multiple, rapidly repeated orgasms throughout life. Excitement On a physiological level sexual excitement is produced in males and females by vasocongestion of the genital organs. The in creased volume of blood in the genitalia results in penile erection in males, and in vaginal lubrication and swelling in females (Kaplan, 1974; Masters and Johnson, 1970). The excitement phase of the female sexual response cycle, vagi nal lubrication and swelling, diminishes significantly with the se nescence of the ovaries at menopause, when ovarian estrogen pro duction ends. The resulting estrogen deficiency leads to the gradual and progressive vaginal atrophy and dryness, along with
190 KAPLAN
Phase I Orgasm
Female
Male A. Significantly lengthened refractory period
A. No effect
B. Decreased volume of ejaculate n Excitement
III Desire
A. Erections less firm B. Older men require more physical and mental stimulation in order to attain and maintain an erection
A. Vaginal dryness and atrophy—caused by estrogen deficiency
A. Variable—Some men and women maintain sexual desire into their 80s and 90s. Sex drive o f others declines in the menopausal years—testosterone is a factor for both genders. Figure 3.
Sex and the aging process.
the increasing vulnerability o f the genitalia to physical trauma, which are experienced to varying degrees by older women, unless they receive replacement therapy. The appropriate use o f nonste roidal lubricants can do much to prevent genital discomfort and dyspareunia in sexually active postmenopausal women. The male excitement phase, erection, is also affected by the aging process, but not as severely. TVvo aspects of these changes are clinically significant: The erections become softer, and the need for stimulation increases (Wagner and Green, 1983). The pressure in, side the penis during erection, which is correlated with its hard ness, normally diminishes with age. However, in healthy men whose penile circulation remains intact, the intrapenile blood pres sure remains high enough to provide rigidity sufficient for vaginal penetration until the end of life. In young men, either physical or psychological stimulation can produce erection, but when they get older, men require concomi tant physical and psychic stimulation in order to attain and main tain an erection. In other words, a man in his 20s can merely look
SEX, INTIMACY, AND AGING 191
at his attractive, nude, and available partner, or even fantasize about her, and he will regularly attain a spontaneous erection from the visual or mental input alone. But when he is 60, he will seldom if ever erect spontaneously as he approaches his partner, nor can he count on remaining erect unless he receives continuous physical penile stimulation. This diminished erectile responsiveness (presbyrectia) is frequently an important factor in the dynamics of the sexual dysfunctions of elderly patients. Desire Feelings of sexual desire are the experiential concomitants of the physiological activity of certain sex centers and circuits in the brain. These depend for their proper functioning, along with cer tain other neurochemical conditions, on critical levels of testos terone. In the absence of testosterone, the CNS sex centers cannot function, and therefore the individual cannot feel sexual passion, although, of course, the sex centers and sexual desire can also be inhibited by depression and other psychological stressors in per sons with normal testosterone levels. Males require higher levels of testosterone than females do, but both genders need this substance to maintain a normal libido. The effect of age on sexual desire in both males and females is highly variable. Some men and women experience no perceptible decline in their sexual passions as they age, while others seem to lose their sex drive altogether. Glandular production of testos terone also varies considerably in otherwise healthy older people, and in some cases, the loss of sex drive can be directly attributed to a parallel decline in serum levels of this hormone. Most women produce sufficient adrenal androgens to retain their interest in sex after their ovaries cease functioning at meno pause. However, in our clinical experience, in approximately 1520% of postmenopausal women, and especially in those who un dergo a surgical menopause, adrenal production of testosterone is not sufficient to sustain libido. Such patients respond very well to -replacement therapy with low doses of androgenic substances. Similarly, the testosterone level of some men, along with their sexual interest, remains high until advanced old age, while an un known but significant proportion of healthy older men experience a climactric that is similar to the female menopause. In males this is characterized by a decreased testicular output of testosterone, along with symptoms of hypoactive sexual desire and a lower ener-
192 KAPLAN
gy level. In these cases also, the administration of supplementary testosterone can restore libido. (See Figure 4.) HEALTHY ADAPTATIONS: MAINTAINING SEXUAL FUNCTIONING In the light of all these changes, one might wonder how it is that so many older people manage to remain sexually active. We have gained some insight into this matter from our detailed studies of the sexual responses and behaviors of the hundreds of elderly men,
Age Related Changes
Adaptations and Management
1. Vaginal dryness and atrophy; dyspareunia
1. Use of lubricant prior to coitus 2. Estrogen replacement 3. Intercourse on a regular basis 4. Dilators
2. Diminished sexual desire—male and female
1. 2. 3. 4.
3. Lengthened male refractory period
1. Less frequent intercourse; empha size quality vs. quantity
4. Softer penile erections
1. Use coital positions which facilitate intromission (stuffing, etc.) 2. No condoms 3. More reliance on manual and oral stimulation 4. More emphasis on clitoral orgasm
5. Higher penile threshold for mental and physical stimulation
1. More partner-provided physical simulation 2. More rapid love making 3. Erotica and fantasy 4. A.M. sex*
Figure 4.
Tfestosterone replacement Fantasy and erotica Treatment of depression Treatment of substance abuse
Maintaining sexual functioning in the postmenopausal couple.
SEX, INTIMACY, AND AGING 193
women, and couples who have sought our help for their sexual difficulties. These extensive clinical observations have made it clear that loving couples who have a harmonious marriage, who enjoy an intimate and caring relationship that includes a commit ment to each other’s pleasure, and who are also sexually open and free of significant conflict, intuitively and gradually adapt to these physical changes without missing a beat. Elderly couples who are emotionally close and empathic and sensitive to each other’s feelings, and secure in each other’s love, sense the other’s changing needs and vulnerabilities, and they intu itively help each other function. The sensitive wife knows, without a word being spoken, that her husband is now more dependent on her for stimulation and support, and much more vulnerable to becoming impotent in response to any performance demands she might make. So, she is now extra careful not to criticize his sexual performance. She is instinctively protective of his feelings, and she is not offended by, nor does she comment on, the fact that he no longer has spontaneous erections when he approaches her. She now supplies him with more intense and active penile stimulation, perhaps trying oral sex, which can be very helpful for older men, without being asked. She does not expect her husband to maintain his erections as long as he did in the past. She senses that if he should try to do so, he may lose his erection and slide into a downwardly spiralling cycle of performance anxiety impotence. With tact and sensitivity she encourages him to climax at his own rhythm, and accepts his manual or oral stimulation, after he has ejaculated, without making him feel that he has failed her. She is not threatened by his increasing need for fantasy, but encourages him to experiment with erotica, and tries to “get into it” with him. She realizes that her elderly husband now functions better in the morning, and she does not make a power struggle out of preferring evening sex. When he does have an occasional erectile failure, she minimizes this, and reassures him that she will be available when he is ready to try again, and that he will probably have better luck next time. - On his part, the husband senses the greater physical vulnerabili ty o f his wife’s aging genitalia, and he is gentler now and more patient in his lovemaking. He does not take her using a lubricant prior to lovemaking as a personal rejection, nor as a loss of her femininity and attractiveness, but encourages her to protect her self. Most important, he becomes more attentive, and he makes an effort to make her feel desirable and attractive, and he is very
194 KAPLAN
careful not to threaten his postmenopausal wife with complimen tary comments about, or by behaving seductively toward, younger women. If she likes to have sex more often than his lengthened refractory period allows, he does not become defensive or nasty. He derives pleasure from making love to his wife in ways that end in a climax for her, but not necessarily for him. This ideal kind of intimate and loving couple intuitively com pensates for the changes in their own and their partner’s dimin ished genital responsiveness, be these the consequence of the nor mal aging process, and/or the results of certain medical problems that become increasingly prevalent with age. Thus they are able to remain sexually functional and active until advanced old age. MALADAPTION: PREMATURE LOSS OF SEXUALITY Sexual difficulties follow in the absence of such ideal condi tions. If. these normal age-related changes occur in a setting of latent marital hostility, or if this happens to a detached couple who lack intimacy and empathy for each other and who do not commu nicate well, minor physical impairments can escalate into severe sexual disabilities. Similar sexual dysfunctions can develop if ei ther partner has puritanical feelings of shame and guilt about sex, or if the physical slowdown taps into either’s preexisting sexual anxieties or neurotic conflicts. Negative Sexual Attitudes of Cultural Origin Some couples are unable to adapt to the aging process because they are still under the influence of the crippling antisexual mes sages that are imparted to children who are raised in highly tradi tional or devoutly religious subcultures! Couples with such moral istic backgrounds typically have sex in a stereotyped manner. They usually have intercourse in the missionary, or male superior posi tion only, and they tend to avoid oral or even manual stimulation. Since they have been brought up to feel ashamed of their sexual feelings and guilty about sexual pleasure and masturbation, they are uneasy about allowing themselves to enjoy erotic fantasies, and, especially if they are aroused by imagining different partners or by paraphyllic visions, they attempt to suppress these altogether. Couples with such culturally determined inhibitions often function well when they are young. But, unfortunately, since fantasy and
SEX, INTIMACY, AND AGING 195
direct genital stimulation are key elements in adapting to the agerelated sexual changes, they may experience serious difficulties when they reach 50 or 60. Individuals who were raised in an environment that regards talk ing about sex as shameful are anything but intimate about sexual matters, and this can also lead to difficulties as they age. Thus for example, in a common clinical scenario, the husband, because he believed this would enable his wife to reach a climax, has “manful ly” struggled over the years to hold back his ejaculations. When a man is young, he can get away with such intense performance pressure. But this is a common cause of late-occurring impotence. When this issue emerges during therapy, it often turns out that the husband’s pressure was self-imposed because he actually never knew whether his wife was orgastic—on intercourse, or on clitoral stimulation, or for that matter whether she had orgasms at all, because the matter was never discussed. Conservative couples with sexual complaints often truly love each other, and they are frequently free of significant psychopath ology. But they simply lack the sexual openness, the flexibility, the knowledge, the intimacy, and the sensitivity to each other’s sexual desires, and also the communication skills that are needed to help each other remain functional in the face of the age-related slow down of their sexual responses. Neurotic Sexual Conflict Couples can also get into difficulty if their age-related sexual slowdown taRS into one or both partners’ preexisting sexual inse curities or his or her neurotic conflicts about sex, intimacy and love. As they age, all men become more vulnerable to the physiologi cal effects of performance anxiety and also to pressure from their partner, and this vulnerability is heightened in those who are inse cure and/or conflicted about sex. The man who has been able to function despite his long-standing doubts about his sexual adequa cy or masculinity in his youth, when his sexuality was vigorous, will tend to overreact, sometimes to the point of panic, when he finds that he cannot get spontaneous erections any more, and that he now needs much more penile stimulation in order to remain hard. Keep in mind that a man’s negative thoughts about his sexual performance are not simple cognitive events. Performance anxiety, like any o th e r form of anxiety, is accompanied by the release of
196 KAPLAN
adrenaline and noradrenaline into the circulation. These sub stances reverse the erectile process instantly, on a physical basis, and it takes only a few repetitions of performance anxiety impo tence to initiate a chronic potency problem. Men with residual oedipai problems and/or those who have nev er resolved their childish dependency on their mothers often find it difficult to remain sexually functional as they age because they are conflicted about accepting their increasing sexual dependency on their wives. A mature and supportive partner can often help a man overcome or “bypass” these difficulties, but if the partner has neurotic problems of her own, her anxiety can intensify and com plicate the aging man’s problem. The rejection sensitivity of emotionally insecure or narcissistic women frequently heightens when they reach the menopausal years and lose their youthful appeal, and they are then unable, in their fragile emotional state, to handle their aging husband’s diminished responsiveness, or to provide the support that he now needs in order to remain functional. In fact, such fragile women are often so threatened by what they perceive as a loss of their sexual pow ers, that they obsessively increase their sexual demands on their partners in a futile attempt to reassure themselves that they are still desirable. When they reach the mid-life years, detached persons who have neurotically avoided intimacy frequently.get in trouble because they lack the emotional qualities that people need to cope with their own biological slowdowns and/or that of their partners. I have seen a number o f men who lacked emotional closeness with their wives, who could not communicate, who did not trust that they would be loved even though they might no longer be able to perform “perfectly,” elect to forego sex altogether, rather than risk sexual failure. Thor close this despite the pain that the loss of their sexuality caused them and their partners. In other cases, such nonintimate men try new, younger partners, sometimes with de structive consequences. For example, a couple who had been married for 33 years came to the office in a crisis that was created when the wife learned that her husband has been sleeping with their maid, an illegal Polish immigrant. The husband, a highly successful, work-oriented, emo tionally closed off, noncommunicative man, confessed this with great embarrassment after he had received a blackmail threat from the maid’s psychopathic lover. The husband, although he found his wife attractive, had
SEX, INTIMACY, AND AGING 197
avoided sex with her for the past five years because o f his fear of impotence. Although he sensed that oral sex, a long-standing fan tasy of his, would help him function, it did not even occur to him to ask this of his wife. He had no such inhibitions with the maid, with whom he enjoyed fellatio. It turned out that the wife had never had an orgasm, and that she had been feeling left out of the “sexual revolution.” Her hus band, who had discouraged all intimate conversation, was sur prised to learn that she was much more upset about his emotional detachment than about his affair, and that she was quite ready to learn about oral sex. Marital Disharmony
>
Sexual problems often develop when age-related physiological changes occur in couples who have been engaged in a long-stand ing power struggle and, instead o f helping each other function, now act out their war in bed. Women, even if they are free of significant psychopathology, will often experience some sense of vulnerability when they approach menopause, are confronted with the loss of their reproductive functioning, and have to compete with younger and more attractive women. When a hostile husband senses his menopausal wife’s insecurity, instead of being support ive and loving and extraattentive, which would, of course, help her remain sexually responsive, he may use this opportunity to act out his long-suppressed rage and manage to make her feel worse. For example, the onset of a sexual avoidance of two years’ duration in one middle-aged couple could be traced to the following incident. The husband, who had been quietly furious at his beautiful wife for years because he felt helpless in the face of her rejections and her manipulations, said to her as she was coming to bed, “Look at that, honey, your pubic hair is turning white. Don’t you think you should color it next time you do your hair?” This was not an intimate couple. They did not understand each other’s feelings. The husband did not know how to assert himself effectively, and, instead, he acted passive-aggressively. The wife, who also lacked the psychic tools to diffuse their mutual hurt and anger, did not reply. But not surprisingly, this woman, who felt humiliated and wounded by her husband’s cruel remark, did not become aroused during the sexual act. Instead, she focused on the mild discomfort of having intercourse with insufficient lubrica-
198 KAPLAN
tion, and claimed that intromission was now physically painful, and henceforth avoided all sexual contact. Their aging husbands’ increasing sexual dependency also gives passive-aggressive wives an unparalleled opportunity to act out their anger in the bedroom. In a typical case of this kind, the wife, who for many years has been in a less powerful position than her husband and has carried a smoldering hidden resentment on that account, becomes aware, often without realizing this consciously, of her husband’s growing sexual vulnerability. Instead of support ing him and helping him function, she makes sure, often without being aware of what she is doing, that he will not succeed. Subtly, she heightens his insecurity, by pressuring him to have sex when he is tense or tired, or by withholding the stimulation and/or support that he now increasingly needs from her. For example, I recently suggested to a patient who was, on one level, extremely distressed by her 65-year-old husband’s impotence, that she stimulate his genitalia manually using a lubricant, prior to insertion. She did her assignment. But this woman, who had been angry at this rather obnoxious, bossy man for two decades, insisted that they do their “homework” at midnight, after an exhausting day, and she did it with obvious contempt and distaste while remarking, “Isn’t it a shame that you need all this fancy stimulation now? You used to be such a great stud.” PSYCHOSEXUAL REHABILITATION The outcome of treatment of elderly couples with sexual com plaints depends first and foremost on an accurate, comprehensive evaluation that includes a precise assessment of both the psycho logical and the organic parameters of the problem. Many avoid able sexual difficulties and treatment failures can be directly attrib uted to the clinician’s lack of knowledge about the complex interplay between physiological and psychodynamic elements in the pathogenesis of the elderly patient’s sexual complaints, and his " or her failure to evaluate these accurately. Organic Elements* Until recently, it had been assumed that sexual disorders are almost invariably psychogenic. However, the extensive clinical ex perience that has been accumulated in the past decades has made it ♦The organic causes of sexual disorders are described in Kaplan, 1983.
SEX, INTIMACY, AND AGING 199
clear that organic factors are highly prevalent in older people. In our experience, and in those of others, disease states that affect the sexual organs, and medications with sexual side effects, play a role in the sexual complaints of approximately 50% of patients who are over the age of 50. Clearly these must be considered in the evalua tion and management of these patients. (See Figure 5.) However, the organic deficits that afflict elderly patients are seldom total. Their severity varies from the mild changes of the normal age-related slowdown in the functioning of the genital or gans that have been described above, and the equally mild circula tory and hormonal deficits and drug effects that are extremely common in older people, to the less frequently seen total physical disability that occurs, for example, with certain surgical proce dures and in advanced diabetes. Most elderly patients with sexual complaints whom we see in
P hase
I Orgasm
II Excitement
m Desire
Figure 5.
M ale
Female
R.E.
Anorgasmia
1. MAOIs 2. Testosterone deficiency
2 . 'testosterone
Impotence 1. Penile vasular insufficiency 2. Beta blockers 3. Anti-hypertensives 4. Diabetes
1. MAOIs deficiency 3. Advanced diabetes
Vaginal Dryness and Atrophy 1. Estrogen deficiency a. Menopausal b. Anti-estrogens
Hypoactive Sexual Desire 1. Testosterone deficiency 2. Prolactin secreting adenoma 3. Depression 4. Beta blockers 5. Alcohol 6. High doses of psychoactive medications Common physical causes o f sexual dysfunction (all increase with age).
200 KAPLAN
our clinical practice retain enough physiological capacity so that they ought to be able to function. However, in the typical case, although there is only a minor degree o f physical impairment, this has been inflated into a severe sexual disability by a variety of intrapsychic and interpersonal stressors. Fortunately these are fre quently amenable to treatment. It is the aim of psychosexual thera py to eliminate the emotional factors that aggravate these partial physical impairments, and to help the couple accept appropriate compensatory sexual techniques. For the purpose of sexual rehabilitation (as opposed to the as sessments done by some urologists whose objective it is to select candidates for penile implant surgery), it is important not only to delineate the precise level o f the patient’s physiological impair ment, but also to ascertain his remaining sexual reserves, so that realistic treatment goals and strategies can be established. If there is any question of organicity, our pre-sex therapy work-up for elderly patients with sexual complaints includes comprehensive hormone screening, nocturnal penile tumesence monitoring (NPT), papaverine testing for penile circulation, and when indicat ed, genital neurophysiological studies (Kaplan, 1983). PSYCHOSEXUAL THERAPY WITH ELDERLY PATIENTS Brief sex therapy is often successful with elderly patients who have functioned well in the past but are now having sexual prob lems because they cannot handle the partial physical deficits that are related to the aging process. Sex therapy is a brief method of treatment that utilizes an integrated amalgam of behavioral tech niques, in the form of specifically structured sexual interactions that the couple conducts in the privacy of their home, and psy chotherapeutic office sessions that the couple usually attends to gether.* Modifying Maladaptive Sexual Behavior The objective of the behavioral assignments is to modify the immediate causes of the patient’s sexual symptoms, such as for *Sex therapy techniques and their underlying theories have been described in detail elsewhere (Kaplan, 1974,1979,1987).
SEX, INTIMACY, AND AGING 201
example, performance anxiety. AH the behavioral protocols that have been developed for the various psychosexual dysfunctions are useful for elderly patients, and, in addition, we prescribe sexual techniques that are designed to compensate for the older couple’s specific physical and emotional limitations. In many respects the assignments incorporate the adaptive behaviors and compensa tions that some elderly couples intuitively use to maintain their sexual relationships, as has been previously described. No single behavioral protocol would be effective for this diverse patient population, and therefore the therapeutically structured interactions are individualized to fit each couple’s particular physi cal limitations and emotional needs. The following are some exam ples of behavioral assignments that are typically prescribed for older patients. Behavioral methods, such as the sensate-focus exercises, which are excellent for diminishing performance anxiety to which the older male is now more vulnerable, are often indicated for the older couple (Masters and Johnson, 1970). Assignments that expo se them to previously avoided physical and emotional intimacies are frequently employed with this patient population. Freeing up sexual fantasy and, in some cases, encouraging the sharing of erotica can help numbers o f older persons to remain functional. Sexual techniques that entail more tender and gentler lovemaking and the use of lubricants are often prescribed to protect the post menopausal woman’s more fragile genitalia. We frequently devise assignments that are designed to improve the husband’s lovemak ing skills and his technique of stimulating his wife’s genitalia, to make up for his softer erections, longer refractory period, and the shorter period of penile thrusting that he is now able to provide for his partner. As a general rule we attempt to shift the couple’s objective in lovemaking away from lengthy penetration and toward the exchange of sensuous pleasure in other ways, and we encourage them to experiment with alternate forms of sexual gratification. This deemphasis on coitus can provide more pleasure for the wom an and reduces the man’s performance pressure for the aging man. Psychodynamic Aspects of Treatment The therapeutic sessions with elderly couples are devoted, in part, to providing them with accurate information about the ef fects of the aging process on the sexual response cycle, and to
202 KAPLAN
clarifying their particular deficits as well as their remaining capaci ties. We try to help patients to accept these biological changes in their sexuality in a constructive, positive, and realistic manner—on the premise that “some has been taken, but much endures.” But perhaps the most important function o f the office sessions, and the most demanding and challenging for the therapist, is to resolve the couple’s resistances to treatment. The structured thera peutic sexual interactions that are prescribed for these patients are not mere mechanical exercises or “sex lessons.” Some o f the as signed sexual experiences have profound emotional and symbolic meaning for the patient and/or the partner. Thus the process o f sex therapy, as well as its outcome, can be threatening to the symptom atic partner and to the spouse as well. The active assault on the couple’s defenses, which is often required, tends to heighten their vulnerabilities, and this typically generates anxieties and mobilizes resistances to treatment. It is essential for a successful treatment outcome to overcome, resolve, or “bypass” these resistances, and this is the major function of the therapy sessions. It is beyond the scope o f this article to describe our methods of resolving resistances in sex therapy, except to indicate that we use brief, active interventions that balance confrontation with sup port, which are based on a psychodynamic theoretical model. Our method of employing progressively “deeper” confrontations and interpretations to “bypass” or resolve resistances has been de scribed in detail elsewhere (Kaplan, 1974,1979, 1987). Resistance The following are some specific issues that create resistances in elderly patients undergoing sexual therapy. Many of the assign ments that are prescribed for older couples entail the wife’s taking a more active role in lovemaking, while the husband learns to accept a more passive or “receiving” position. Not surprisingly, such experiences and role shifts that have previously been avoided because they are threatening, often evoke intense anxiety and resis tance, despite the fact that on a cognitive level, the couple is given to understand that this is necessary if they are to remain sexually functional. The introduction of erotica or fantasy is another common source of resistance. Rejection-sensitive wives are often threatened by the therapist’s suggestion to their husbands that they “tune out” their performance anxieties and obsessions by focusing on a sexual
SEX, INTIMACY, AND AGING 203
fantasy. A woman who is emotionally fragile may be threatened if her partner desires anyone but her, often taking this as an indica tion that she is no longer desirable. In one such case, the wife’s persistent resistance to fantasy was an insurmountable obstacle to treatment. During the therapy sessions, she was repeatedly con fronted with the reality that her aging husband was merely trying to compensate for his physiological limitations. Treatment did not move forward until the wife gained insight into her transferential distortions, and came to realize that her husband’s need for erotica was not her father rejecting her all over again, but that her loving husband was simply trying to do his very best to sustain his erec tion so he would not dissappoint her. Not infrequently, the process of sexual therapy evokes latent marital hostilities that must also be resolved during the sessions if therapy is to succeed. The case mentioned above where the hus band’s passive-aggressive remark about his wife’s white pubic hair precipitated the couple’s sexual avoidance serves to illustrate this point. These spouses were initially too angry at each other to be able to commit themselves to or benefit from sexual assignments that were meant to heighten their enjoyment together. It was neces sary first, in the conjoint sessions, to confront this couple’s hidden power struggles, and to resolve their intense anger toward each other before they were able to stop sabotaging and to respond to sexual therapy. MAINTAINING SEXUAL FUNCTIONING IN MATURITY It is important for clinicians to realize that asexuality is not a normal part of the aging process. Doctors and therapists should not dismiss their mature patients’ sexual complaints as unavoid able aspects of aging, because, thanks to the recent advances in sexual medicine and the development of psychosexual therapy methods especially geared to this population, sexual functioning can be restored or materially improved in a high proportion of elderly patients. The prognosis is especially good for couples who had enjoyed a good sexual relationship prior to the onset o f agerelated changes in their sexual functioning. In addition, an avoidance o f intimacy and an inability to com municate effectively are frequently central issues in the dynamics of the sexual problems of the elderly. Therefore the improvement of the couple’s" emotional closeness and o f their communication
204 KAPLAN
with each other is a major focus of treatment in many cases. When this is successful, and it often is, the process of conjoint psychosexual therapy can result in a long-lasting improvement in the couple’s relationship, which is a most welcome extra benefit above and beyond the reconstruction of their sexual functioning. Although it is widely believed that sex no longer matters after middle age, the opposite is true, and sex often becomes more and not less important as a person grows older. Because sex is among the last pleasure-giving biological processes to deteriorate, it is potentially an enduring source o f gratification at a time when these are becoming fewer and fewer, and a link to the joys of youth. These are important ingredients in the elderly person’s emo tional and physical well-being. The aging process entails the acceptance o f many losses, losses of physical ability and health, o f power, o f social importance, often o f money, and so on. But if a 70-year-old woman can still excite her husband, and if she can still experience sexual pleasure and orgasm, she is less likely to feel that she has lost everything, including her sexual powers, and that she is now an old lady whom nobody wants. If she can maintain a sexual connection with her partner, she is apt to feel good about herself, even if she has a little arthritis, even if she has had to give up skiing, and even if the kids don’t call all that often, and she will be moved to make the effort to take care of herself and to remain attractive to her husband. Her retired husband might feel less lost and emotionally impotent, although he no longer has an attentive staff to do his bidding, although he has presbyopia and a hearing loss, and even if he can no longer win the tennis trophy, if he can still give pleasure to and “make it” with an attractive woman. The maintenance of sexual functioning in the elderly is also very worthwhile from a broader clinical perspective, because the pre mature loss of sexual functioning can contribute to emotional and physical deterioration in older persons. References Brecher, E. M ., and the Editors o f Consumer Reports Books (1984), Love, Sex and Aging, Little, Brown & C o., Boston. George, L. K., and Weiler, S. J. (1981), Sexuality in middle and late life, Arch. Gen. Psychiat., 3 8 , 919-923. Kaplan, H. S. (1974), The New Sex Therapy, Brunner/Mazel, New York. Kaplan, H . S. (1979), Disorders o f Sexual Desire, Brunner/Mazel, New York.
SEX, INTIMACY, AND AGING 205 Kaplan, H. S. (1983), The Evaluation o f Sexual Disorders: Psychological and Medical Aspects, Brunner/Mazel, New York. Kaplan, H . S. (1987), Sexual Aversion, Sexual Phobias, and Panic Disorder, Brunner/Ma zel, New York. Kinsey, A . C ., Pomeroy, W. B., and Martin, C. E. (1948), Sexual Behavior in the Human Male, W. B. Saunders, Philadelphia. Kinsey, A . C ., Pomeroy, W. B., and Martin, C. E. (1953), Sexual Behavior in the Human Female, W. B. Saunders, Philadelphia. Masters, W. B., and Johnson, V. E. (1966), The Human Sexual Response, Little, Brown and C o., Boston. Masters, W. B., and Johnson, V. E. (1970), Human Sexual Inadequacy, Little, Brown and C o., Boston. Palmore, E. (Ed.) (1970), Normal Aging, Duke University Press, Durham, NC. Palmore, E. (Ed.) (1974), Normal Aging II, Duke University Press, Durham, NC. Starr, B. D ., and Weiner, M. B. (1981), The Starr-Weiner Report on Sex and Sexuality in the Mature Years, McGraw-Hill, New York. ' Todarello, O ., and Boscia, F. M. (1985), Sexuality in aging: A study o f a group o f 300 elderly men and women, J. Endocrinol. Invest., 8 (Suppl. 2), 123-129. Wagner, G., and Green, R. (1983), Impotence, Plenum Press, New York. Weizman, R ., and Hart, J. (1987), Sexual behavior in healthy married elderly men, Arch. Sex. Behav., 1 6 , 39-44.
The New York H ospital Cornell Medical Center 525 East 68th Street New York, NY 10021
HELEN S. KAPLAN, M .D., Ph.D.*
The loss of sexuality is not an inevitable aspect of aging, and the majority of healthy people remain sexually active on a regular basis until advanced old age. However, the aging process does bring with it certain changes in the physiology of the male and the female sexual response, and these along with a number o f medical problems that be come more prevalent in the mature years, play a significant role in the pathogenesis of the sexual disorders of the eldèrly. The typical patient over 50 has only a partial degree of biological impairment, which has, however, been escalated into a total sexual disability by a variety of cultural, intra psychic, and relationship stressors. Fortunately, these problems are frequently amenable to an integrated psychodynamically oriented sex therapy approach that empha sizes the improvement of the couple’s intimacy, and the expansion of their sexual flexibility. The information about age-related sexual disorders as well as the concepts and treatment approaches that are presented in this article are the product o f our observations o f over 400 patients with sexual complaints who were 50 years or older, over the past 10 years.1"* Our method of evaluating couples with sexual dysfunc tions includes, in addition to the customary sexual, psychiatric, and medical histories and examinations, a highly detailed investi gation o f their current sexual status and experiences and behaviors (Kaplan, 1983). This has enabled us to compare the adaptive be haviors and constructive interactions o f couples who manage to ♦Clinical Professor of Psychiatry and Director of the Human Sexuality Pro gram, The New York Hospital-Comell Medical Center. This article developed from a talk at the American Academy of Psychoanaly sis, October 1,1988, New York City. - **The age range of our population was 50-92, and included single patients as well as couples, wherein one or both partners were in that age group. The patients were seen by myself and my associates at the Human Sexuality Program of the New York Hospital-Comell Medical Center, and also in our private practice group. " Journal o f The American Academy o f Psychoanalysis, 18(2),'185-205, 1990 © 1990 The American Academy o f Psychoanalysis
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function and to enjoy sex until advanced old age with the maladap tive behaviors and the destructive interactions of those who devel op sexual dysfunctions or who cease having sex altogether after their menopausal years. This rich clinical experience has yielded many valuable insights into the pathogenesis o f sexual disorders in the elderly, and has clarified the important role that intimacy plays in a couple’s healthy adaptation to the aging process. SEX AND THE AGING PROCESS There is a widely held belief in our society, which is shared by the general public and health professionals alike, that sex is among the first biological functions to fall prey to the aging process. But this is a myth. Actually, sexuality is among the last o f our faculties to decline with maturity. From an embryological perspective, we age “from the outside in,” so to speak. We begin life as three tiny concentric tubes, from which the different organs develop. The outer or exodermal layer of the embryo develops into skin, the sensory organs, and the nervous system, and these are the tissues that begin to show agerelated changes first. Thus in our 40s, our skin begins to wrinkle, we start using reading glasses, and we find ourselves having trouble remembering the names of people we meet at cocktail parties and seminars. Sometime later, the middle, or mesodermal tissues, begin to show senescence. The embryologic middle layer produces our mus cles, bones, connective tissue, and blood vessels, and in the 50s, cardiovascular diseases and musculoskeletal problems such as ar thritis and the rheumatic disorders make their appearance. Breathing, eating, and sex, the functions o f the organ? that are derived from the innermost tube or endodermal layer, endure the longest. So, most of us are still sexually active long after we have begun to use hearing aids and eyeglasses, and some of my elderly - patients are still enjoying good sex, although they cannot always remember the name of their partner. SEXUAL ACTIVITY AND AGING s
During the past 40 years, the sexual behaviors of thousands o f American men and women between the ages of 50 and 100 have been scientifically investigated (Kinsey et al., 1948, 1953; Masters and Johnson, 1966, 1970; Palmore, 1970, 1974; Starr and Weiner,
SEX, INTIMACY, AND AGING 187
1981). The results of these studies are remarkable in their consen sus: Without exception, each investigator found that, providing they are in good health, the great majority of people remain sexu ally functional and active on a regular basis until virtually the end of life. Or, to put it more succinctly, 70% of healthy 70 year olds remain sexually active, and are having sex at least once a week, and typically more often than that. (See Figure 1.) These findings are entirely consistent with our own clinical experience. AGE-RELATED CHANGES IN SEXUAL FUNCTIONING I do not mean to imply that we retain our full youthful sekuality all our lives. There are, of course, certain inevitable age-related changes in sexual physiology, and these affect men and women differently. More specifically, male sexuality peaks sharply at around 17 and then gradually declines, whereas women do not reach their full sexual potential until their late 30s or early 40s, and then they slow down to a lesser degree than men. Moreover, the aging process does not result in general sexual decline, but has a specific and different impact on each of the three phases of the human sexual response cycle. (See Figures 2 and 3.) Below is a brief summary of those age-related biological changes that are of special clinical significance because of their role in the pathogene sis of the sexual complaints of the elderly. Orgasm Orgasm in males and females consists of the reflex rhythmic contractions of certain genital muscles (the ischiocavernosii and the bulbocavernosii muscles), which are normally perceived as highly pleasurable. In the male, these muscles are located at the base of the penis, and their 0.9-per-second spasms eject semen through the urethra out of the tip of the penis. Analogous 0.9-persecond contractions of the same genital muscles, which in females are located around the vaginal introitus, produce the sensations of female orgasm (Kaplan, 1974). ♦The results of a European and an Israeli study of sex and aging are strikingly similar to the U.S. findings, namely that the great majority of healthy people remain sexually functional and active on a regular basis into advanced old age (Tbradella and Boscia, 1985; Weitzman and Hart, 1987).
S tu dy
Year
1. Kinsey Reports
19481953
N
212 O' 152 9
A ge Range
51-90 51-80
70% of couples are sexually active at age 70 on a regular basis. The average frequen cy over 70 is 0.3 times a week.
50-90
Found men and women in all age groups who remain sexually active on a regular basis.
'E 364
2.
Masters and Johnson
19661970
150 0 * 212 9
E 362 3. Duke University Longitudinal Study
19531965
o*+9
1968present
o*+9
250 60-90
502 45-69
E 752 4.
1981
Starr- Weiner R eport on Sex a n d Sexuality in the M ature Years
280 0 * 520 9
60-91
E 800 -
5. Consumer Union Survey: Love, Sex,
1984
4,200
Figure 1.
188
1984present
6,478
a+9
70% of physically healthy couples have regular intercourse at the age of 68. In some cases, the frequency of sexual intercourse increases. 80% of total sample (O’ & 9 ) are sexually active. 50% have sex on a regular basis. Of these, 50% have intercourse once a week or more often.
50-93
79% of men, and 65% of women aged 70-91 are sexually active on a regular basis. 58% O* and 50% 9 have sex every week.
50-93
The majority of physically healthy men and women remain sexually active on a regular basis into the seventh decade and beyond.
o*+9
an d A gin g
All studies combined
O u tcom e
Sex and the aging process: Summary o f recent studies.
SEX, INTIMACY, AND AGING 189
Male
Phase I Orgasm Genital Muscle Spasm
A. Emission Contraction of internal muscles
B. Ejaculation
Female A. No emission B. Q orgasm Perineal muscle contractions
Perineal muscle II Excitement Genital Vasocongestion III Desire Activation of brain sex centers
Erection
Lubrication—Swelling
High blood pressure system in penis
Diffuse genital vaso congestion
Sexual Passion or Libido
'
Activation of specific CNS areas—mediated by tes tosterone in both genders
Figure 2. The three phases o f the sexual response cycle. In males, the refractory period increases substantially with age. The refractory period is that length o f time that must elapse after a man has ejaculated, before he can be stimulated to another climax (when he is refractory to further sexual stimulation). This interval lengthens from just a few minutes at the age of 17, to as much as 48 hours by the age of 70. In contrast, women, probably because they do not ejaculate, do not have a significant refractory period at any age, and remain physically capable of experiencing multiple, rapidly repeated orgasms throughout life. Excitement On a physiological level sexual excitement is produced in males and females by vasocongestion of the genital organs. The in creased volume of blood in the genitalia results in penile erection in males, and in vaginal lubrication and swelling in females (Kaplan, 1974; Masters and Johnson, 1970). The excitement phase of the female sexual response cycle, vagi nal lubrication and swelling, diminishes significantly with the se nescence of the ovaries at menopause, when ovarian estrogen pro duction ends. The resulting estrogen deficiency leads to the gradual and progressive vaginal atrophy and dryness, along with
190 KAPLAN
Phase I Orgasm
Female
Male A. Significantly lengthened refractory period
A. No effect
B. Decreased volume of ejaculate n Excitement
III Desire
A. Erections less firm B. Older men require more physical and mental stimulation in order to attain and maintain an erection
A. Vaginal dryness and atrophy—caused by estrogen deficiency
A. Variable—Some men and women maintain sexual desire into their 80s and 90s. Sex drive o f others declines in the menopausal years—testosterone is a factor for both genders. Figure 3.
Sex and the aging process.
the increasing vulnerability o f the genitalia to physical trauma, which are experienced to varying degrees by older women, unless they receive replacement therapy. The appropriate use o f nonste roidal lubricants can do much to prevent genital discomfort and dyspareunia in sexually active postmenopausal women. The male excitement phase, erection, is also affected by the aging process, but not as severely. TVvo aspects of these changes are clinically significant: The erections become softer, and the need for stimulation increases (Wagner and Green, 1983). The pressure in, side the penis during erection, which is correlated with its hard ness, normally diminishes with age. However, in healthy men whose penile circulation remains intact, the intrapenile blood pres sure remains high enough to provide rigidity sufficient for vaginal penetration until the end of life. In young men, either physical or psychological stimulation can produce erection, but when they get older, men require concomi tant physical and psychic stimulation in order to attain and main tain an erection. In other words, a man in his 20s can merely look
SEX, INTIMACY, AND AGING 191
at his attractive, nude, and available partner, or even fantasize about her, and he will regularly attain a spontaneous erection from the visual or mental input alone. But when he is 60, he will seldom if ever erect spontaneously as he approaches his partner, nor can he count on remaining erect unless he receives continuous physical penile stimulation. This diminished erectile responsiveness (presbyrectia) is frequently an important factor in the dynamics of the sexual dysfunctions of elderly patients. Desire Feelings of sexual desire are the experiential concomitants of the physiological activity of certain sex centers and circuits in the brain. These depend for their proper functioning, along with cer tain other neurochemical conditions, on critical levels of testos terone. In the absence of testosterone, the CNS sex centers cannot function, and therefore the individual cannot feel sexual passion, although, of course, the sex centers and sexual desire can also be inhibited by depression and other psychological stressors in per sons with normal testosterone levels. Males require higher levels of testosterone than females do, but both genders need this substance to maintain a normal libido. The effect of age on sexual desire in both males and females is highly variable. Some men and women experience no perceptible decline in their sexual passions as they age, while others seem to lose their sex drive altogether. Glandular production of testos terone also varies considerably in otherwise healthy older people, and in some cases, the loss of sex drive can be directly attributed to a parallel decline in serum levels of this hormone. Most women produce sufficient adrenal androgens to retain their interest in sex after their ovaries cease functioning at meno pause. However, in our clinical experience, in approximately 1520% of postmenopausal women, and especially in those who un dergo a surgical menopause, adrenal production of testosterone is not sufficient to sustain libido. Such patients respond very well to -replacement therapy with low doses of androgenic substances. Similarly, the testosterone level of some men, along with their sexual interest, remains high until advanced old age, while an un known but significant proportion of healthy older men experience a climactric that is similar to the female menopause. In males this is characterized by a decreased testicular output of testosterone, along with symptoms of hypoactive sexual desire and a lower ener-
192 KAPLAN
gy level. In these cases also, the administration of supplementary testosterone can restore libido. (See Figure 4.) HEALTHY ADAPTATIONS: MAINTAINING SEXUAL FUNCTIONING In the light of all these changes, one might wonder how it is that so many older people manage to remain sexually active. We have gained some insight into this matter from our detailed studies of the sexual responses and behaviors of the hundreds of elderly men,
Age Related Changes
Adaptations and Management
1. Vaginal dryness and atrophy; dyspareunia
1. Use of lubricant prior to coitus 2. Estrogen replacement 3. Intercourse on a regular basis 4. Dilators
2. Diminished sexual desire—male and female
1. 2. 3. 4.
3. Lengthened male refractory period
1. Less frequent intercourse; empha size quality vs. quantity
4. Softer penile erections
1. Use coital positions which facilitate intromission (stuffing, etc.) 2. No condoms 3. More reliance on manual and oral stimulation 4. More emphasis on clitoral orgasm
5. Higher penile threshold for mental and physical stimulation
1. More partner-provided physical simulation 2. More rapid love making 3. Erotica and fantasy 4. A.M. sex*
Figure 4.
Tfestosterone replacement Fantasy and erotica Treatment of depression Treatment of substance abuse
Maintaining sexual functioning in the postmenopausal couple.
SEX, INTIMACY, AND AGING 193
women, and couples who have sought our help for their sexual difficulties. These extensive clinical observations have made it clear that loving couples who have a harmonious marriage, who enjoy an intimate and caring relationship that includes a commit ment to each other’s pleasure, and who are also sexually open and free of significant conflict, intuitively and gradually adapt to these physical changes without missing a beat. Elderly couples who are emotionally close and empathic and sensitive to each other’s feelings, and secure in each other’s love, sense the other’s changing needs and vulnerabilities, and they intu itively help each other function. The sensitive wife knows, without a word being spoken, that her husband is now more dependent on her for stimulation and support, and much more vulnerable to becoming impotent in response to any performance demands she might make. So, she is now extra careful not to criticize his sexual performance. She is instinctively protective of his feelings, and she is not offended by, nor does she comment on, the fact that he no longer has spontaneous erections when he approaches her. She now supplies him with more intense and active penile stimulation, perhaps trying oral sex, which can be very helpful for older men, without being asked. She does not expect her husband to maintain his erections as long as he did in the past. She senses that if he should try to do so, he may lose his erection and slide into a downwardly spiralling cycle of performance anxiety impotence. With tact and sensitivity she encourages him to climax at his own rhythm, and accepts his manual or oral stimulation, after he has ejaculated, without making him feel that he has failed her. She is not threatened by his increasing need for fantasy, but encourages him to experiment with erotica, and tries to “get into it” with him. She realizes that her elderly husband now functions better in the morning, and she does not make a power struggle out of preferring evening sex. When he does have an occasional erectile failure, she minimizes this, and reassures him that she will be available when he is ready to try again, and that he will probably have better luck next time. - On his part, the husband senses the greater physical vulnerabili ty o f his wife’s aging genitalia, and he is gentler now and more patient in his lovemaking. He does not take her using a lubricant prior to lovemaking as a personal rejection, nor as a loss of her femininity and attractiveness, but encourages her to protect her self. Most important, he becomes more attentive, and he makes an effort to make her feel desirable and attractive, and he is very
194 KAPLAN
careful not to threaten his postmenopausal wife with complimen tary comments about, or by behaving seductively toward, younger women. If she likes to have sex more often than his lengthened refractory period allows, he does not become defensive or nasty. He derives pleasure from making love to his wife in ways that end in a climax for her, but not necessarily for him. This ideal kind of intimate and loving couple intuitively com pensates for the changes in their own and their partner’s dimin ished genital responsiveness, be these the consequence of the nor mal aging process, and/or the results of certain medical problems that become increasingly prevalent with age. Thus they are able to remain sexually functional and active until advanced old age. MALADAPTION: PREMATURE LOSS OF SEXUALITY Sexual difficulties follow in the absence of such ideal condi tions. If. these normal age-related changes occur in a setting of latent marital hostility, or if this happens to a detached couple who lack intimacy and empathy for each other and who do not commu nicate well, minor physical impairments can escalate into severe sexual disabilities. Similar sexual dysfunctions can develop if ei ther partner has puritanical feelings of shame and guilt about sex, or if the physical slowdown taps into either’s preexisting sexual anxieties or neurotic conflicts. Negative Sexual Attitudes of Cultural Origin Some couples are unable to adapt to the aging process because they are still under the influence of the crippling antisexual mes sages that are imparted to children who are raised in highly tradi tional or devoutly religious subcultures! Couples with such moral istic backgrounds typically have sex in a stereotyped manner. They usually have intercourse in the missionary, or male superior posi tion only, and they tend to avoid oral or even manual stimulation. Since they have been brought up to feel ashamed of their sexual feelings and guilty about sexual pleasure and masturbation, they are uneasy about allowing themselves to enjoy erotic fantasies, and, especially if they are aroused by imagining different partners or by paraphyllic visions, they attempt to suppress these altogether. Couples with such culturally determined inhibitions often function well when they are young. But, unfortunately, since fantasy and
SEX, INTIMACY, AND AGING 195
direct genital stimulation are key elements in adapting to the agerelated sexual changes, they may experience serious difficulties when they reach 50 or 60. Individuals who were raised in an environment that regards talk ing about sex as shameful are anything but intimate about sexual matters, and this can also lead to difficulties as they age. Thus for example, in a common clinical scenario, the husband, because he believed this would enable his wife to reach a climax, has “manful ly” struggled over the years to hold back his ejaculations. When a man is young, he can get away with such intense performance pressure. But this is a common cause of late-occurring impotence. When this issue emerges during therapy, it often turns out that the husband’s pressure was self-imposed because he actually never knew whether his wife was orgastic—on intercourse, or on clitoral stimulation, or for that matter whether she had orgasms at all, because the matter was never discussed. Conservative couples with sexual complaints often truly love each other, and they are frequently free of significant psychopath ology. But they simply lack the sexual openness, the flexibility, the knowledge, the intimacy, and the sensitivity to each other’s sexual desires, and also the communication skills that are needed to help each other remain functional in the face of the age-related slow down of their sexual responses. Neurotic Sexual Conflict Couples can also get into difficulty if their age-related sexual slowdown taRS into one or both partners’ preexisting sexual inse curities or his or her neurotic conflicts about sex, intimacy and love. As they age, all men become more vulnerable to the physiologi cal effects of performance anxiety and also to pressure from their partner, and this vulnerability is heightened in those who are inse cure and/or conflicted about sex. The man who has been able to function despite his long-standing doubts about his sexual adequa cy or masculinity in his youth, when his sexuality was vigorous, will tend to overreact, sometimes to the point of panic, when he finds that he cannot get spontaneous erections any more, and that he now needs much more penile stimulation in order to remain hard. Keep in mind that a man’s negative thoughts about his sexual performance are not simple cognitive events. Performance anxiety, like any o th e r form of anxiety, is accompanied by the release of
196 KAPLAN
adrenaline and noradrenaline into the circulation. These sub stances reverse the erectile process instantly, on a physical basis, and it takes only a few repetitions of performance anxiety impo tence to initiate a chronic potency problem. Men with residual oedipai problems and/or those who have nev er resolved their childish dependency on their mothers often find it difficult to remain sexually functional as they age because they are conflicted about accepting their increasing sexual dependency on their wives. A mature and supportive partner can often help a man overcome or “bypass” these difficulties, but if the partner has neurotic problems of her own, her anxiety can intensify and com plicate the aging man’s problem. The rejection sensitivity of emotionally insecure or narcissistic women frequently heightens when they reach the menopausal years and lose their youthful appeal, and they are then unable, in their fragile emotional state, to handle their aging husband’s diminished responsiveness, or to provide the support that he now needs in order to remain functional. In fact, such fragile women are often so threatened by what they perceive as a loss of their sexual pow ers, that they obsessively increase their sexual demands on their partners in a futile attempt to reassure themselves that they are still desirable. When they reach the mid-life years, detached persons who have neurotically avoided intimacy frequently.get in trouble because they lack the emotional qualities that people need to cope with their own biological slowdowns and/or that of their partners. I have seen a number o f men who lacked emotional closeness with their wives, who could not communicate, who did not trust that they would be loved even though they might no longer be able to perform “perfectly,” elect to forego sex altogether, rather than risk sexual failure. Thor close this despite the pain that the loss of their sexuality caused them and their partners. In other cases, such nonintimate men try new, younger partners, sometimes with de structive consequences. For example, a couple who had been married for 33 years came to the office in a crisis that was created when the wife learned that her husband has been sleeping with their maid, an illegal Polish immigrant. The husband, a highly successful, work-oriented, emo tionally closed off, noncommunicative man, confessed this with great embarrassment after he had received a blackmail threat from the maid’s psychopathic lover. The husband, although he found his wife attractive, had
SEX, INTIMACY, AND AGING 197
avoided sex with her for the past five years because o f his fear of impotence. Although he sensed that oral sex, a long-standing fan tasy of his, would help him function, it did not even occur to him to ask this of his wife. He had no such inhibitions with the maid, with whom he enjoyed fellatio. It turned out that the wife had never had an orgasm, and that she had been feeling left out of the “sexual revolution.” Her hus band, who had discouraged all intimate conversation, was sur prised to learn that she was much more upset about his emotional detachment than about his affair, and that she was quite ready to learn about oral sex. Marital Disharmony
>
Sexual problems often develop when age-related physiological changes occur in couples who have been engaged in a long-stand ing power struggle and, instead o f helping each other function, now act out their war in bed. Women, even if they are free of significant psychopathology, will often experience some sense of vulnerability when they approach menopause, are confronted with the loss of their reproductive functioning, and have to compete with younger and more attractive women. When a hostile husband senses his menopausal wife’s insecurity, instead of being support ive and loving and extraattentive, which would, of course, help her remain sexually responsive, he may use this opportunity to act out his long-suppressed rage and manage to make her feel worse. For example, the onset of a sexual avoidance of two years’ duration in one middle-aged couple could be traced to the following incident. The husband, who had been quietly furious at his beautiful wife for years because he felt helpless in the face of her rejections and her manipulations, said to her as she was coming to bed, “Look at that, honey, your pubic hair is turning white. Don’t you think you should color it next time you do your hair?” This was not an intimate couple. They did not understand each other’s feelings. The husband did not know how to assert himself effectively, and, instead, he acted passive-aggressively. The wife, who also lacked the psychic tools to diffuse their mutual hurt and anger, did not reply. But not surprisingly, this woman, who felt humiliated and wounded by her husband’s cruel remark, did not become aroused during the sexual act. Instead, she focused on the mild discomfort of having intercourse with insufficient lubrica-
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tion, and claimed that intromission was now physically painful, and henceforth avoided all sexual contact. Their aging husbands’ increasing sexual dependency also gives passive-aggressive wives an unparalleled opportunity to act out their anger in the bedroom. In a typical case of this kind, the wife, who for many years has been in a less powerful position than her husband and has carried a smoldering hidden resentment on that account, becomes aware, often without realizing this consciously, of her husband’s growing sexual vulnerability. Instead of support ing him and helping him function, she makes sure, often without being aware of what she is doing, that he will not succeed. Subtly, she heightens his insecurity, by pressuring him to have sex when he is tense or tired, or by withholding the stimulation and/or support that he now increasingly needs from her. For example, I recently suggested to a patient who was, on one level, extremely distressed by her 65-year-old husband’s impotence, that she stimulate his genitalia manually using a lubricant, prior to insertion. She did her assignment. But this woman, who had been angry at this rather obnoxious, bossy man for two decades, insisted that they do their “homework” at midnight, after an exhausting day, and she did it with obvious contempt and distaste while remarking, “Isn’t it a shame that you need all this fancy stimulation now? You used to be such a great stud.” PSYCHOSEXUAL REHABILITATION The outcome of treatment of elderly couples with sexual com plaints depends first and foremost on an accurate, comprehensive evaluation that includes a precise assessment of both the psycho logical and the organic parameters of the problem. Many avoid able sexual difficulties and treatment failures can be directly attrib uted to the clinician’s lack of knowledge about the complex interplay between physiological and psychodynamic elements in the pathogenesis of the elderly patient’s sexual complaints, and his " or her failure to evaluate these accurately. Organic Elements* Until recently, it had been assumed that sexual disorders are almost invariably psychogenic. However, the extensive clinical ex perience that has been accumulated in the past decades has made it ♦The organic causes of sexual disorders are described in Kaplan, 1983.
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clear that organic factors are highly prevalent in older people. In our experience, and in those of others, disease states that affect the sexual organs, and medications with sexual side effects, play a role in the sexual complaints of approximately 50% of patients who are over the age of 50. Clearly these must be considered in the evalua tion and management of these patients. (See Figure 5.) However, the organic deficits that afflict elderly patients are seldom total. Their severity varies from the mild changes of the normal age-related slowdown in the functioning of the genital or gans that have been described above, and the equally mild circula tory and hormonal deficits and drug effects that are extremely common in older people, to the less frequently seen total physical disability that occurs, for example, with certain surgical proce dures and in advanced diabetes. Most elderly patients with sexual complaints whom we see in
P hase
I Orgasm
II Excitement
m Desire
Figure 5.
M ale
Female
R.E.
Anorgasmia
1. MAOIs 2. Testosterone deficiency
2 . 'testosterone
Impotence 1. Penile vasular insufficiency 2. Beta blockers 3. Anti-hypertensives 4. Diabetes
1. MAOIs deficiency 3. Advanced diabetes
Vaginal Dryness and Atrophy 1. Estrogen deficiency a. Menopausal b. Anti-estrogens
Hypoactive Sexual Desire 1. Testosterone deficiency 2. Prolactin secreting adenoma 3. Depression 4. Beta blockers 5. Alcohol 6. High doses of psychoactive medications Common physical causes o f sexual dysfunction (all increase with age).
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our clinical practice retain enough physiological capacity so that they ought to be able to function. However, in the typical case, although there is only a minor degree o f physical impairment, this has been inflated into a severe sexual disability by a variety of intrapsychic and interpersonal stressors. Fortunately these are fre quently amenable to treatment. It is the aim of psychosexual thera py to eliminate the emotional factors that aggravate these partial physical impairments, and to help the couple accept appropriate compensatory sexual techniques. For the purpose of sexual rehabilitation (as opposed to the as sessments done by some urologists whose objective it is to select candidates for penile implant surgery), it is important not only to delineate the precise level o f the patient’s physiological impair ment, but also to ascertain his remaining sexual reserves, so that realistic treatment goals and strategies can be established. If there is any question of organicity, our pre-sex therapy work-up for elderly patients with sexual complaints includes comprehensive hormone screening, nocturnal penile tumesence monitoring (NPT), papaverine testing for penile circulation, and when indicat ed, genital neurophysiological studies (Kaplan, 1983). PSYCHOSEXUAL THERAPY WITH ELDERLY PATIENTS Brief sex therapy is often successful with elderly patients who have functioned well in the past but are now having sexual prob lems because they cannot handle the partial physical deficits that are related to the aging process. Sex therapy is a brief method of treatment that utilizes an integrated amalgam of behavioral tech niques, in the form of specifically structured sexual interactions that the couple conducts in the privacy of their home, and psy chotherapeutic office sessions that the couple usually attends to gether.* Modifying Maladaptive Sexual Behavior The objective of the behavioral assignments is to modify the immediate causes of the patient’s sexual symptoms, such as for *Sex therapy techniques and their underlying theories have been described in detail elsewhere (Kaplan, 1974,1979,1987).
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example, performance anxiety. AH the behavioral protocols that have been developed for the various psychosexual dysfunctions are useful for elderly patients, and, in addition, we prescribe sexual techniques that are designed to compensate for the older couple’s specific physical and emotional limitations. In many respects the assignments incorporate the adaptive behaviors and compensa tions that some elderly couples intuitively use to maintain their sexual relationships, as has been previously described. No single behavioral protocol would be effective for this diverse patient population, and therefore the therapeutically structured interactions are individualized to fit each couple’s particular physi cal limitations and emotional needs. The following are some exam ples of behavioral assignments that are typically prescribed for older patients. Behavioral methods, such as the sensate-focus exercises, which are excellent for diminishing performance anxiety to which the older male is now more vulnerable, are often indicated for the older couple (Masters and Johnson, 1970). Assignments that expo se them to previously avoided physical and emotional intimacies are frequently employed with this patient population. Freeing up sexual fantasy and, in some cases, encouraging the sharing of erotica can help numbers o f older persons to remain functional. Sexual techniques that entail more tender and gentler lovemaking and the use of lubricants are often prescribed to protect the post menopausal woman’s more fragile genitalia. We frequently devise assignments that are designed to improve the husband’s lovemak ing skills and his technique of stimulating his wife’s genitalia, to make up for his softer erections, longer refractory period, and the shorter period of penile thrusting that he is now able to provide for his partner. As a general rule we attempt to shift the couple’s objective in lovemaking away from lengthy penetration and toward the exchange of sensuous pleasure in other ways, and we encourage them to experiment with alternate forms of sexual gratification. This deemphasis on coitus can provide more pleasure for the wom an and reduces the man’s performance pressure for the aging man. Psychodynamic Aspects of Treatment The therapeutic sessions with elderly couples are devoted, in part, to providing them with accurate information about the ef fects of the aging process on the sexual response cycle, and to
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clarifying their particular deficits as well as their remaining capaci ties. We try to help patients to accept these biological changes in their sexuality in a constructive, positive, and realistic manner—on the premise that “some has been taken, but much endures.” But perhaps the most important function o f the office sessions, and the most demanding and challenging for the therapist, is to resolve the couple’s resistances to treatment. The structured thera peutic sexual interactions that are prescribed for these patients are not mere mechanical exercises or “sex lessons.” Some o f the as signed sexual experiences have profound emotional and symbolic meaning for the patient and/or the partner. Thus the process o f sex therapy, as well as its outcome, can be threatening to the symptom atic partner and to the spouse as well. The active assault on the couple’s defenses, which is often required, tends to heighten their vulnerabilities, and this typically generates anxieties and mobilizes resistances to treatment. It is essential for a successful treatment outcome to overcome, resolve, or “bypass” these resistances, and this is the major function of the therapy sessions. It is beyond the scope o f this article to describe our methods of resolving resistances in sex therapy, except to indicate that we use brief, active interventions that balance confrontation with sup port, which are based on a psychodynamic theoretical model. Our method of employing progressively “deeper” confrontations and interpretations to “bypass” or resolve resistances has been de scribed in detail elsewhere (Kaplan, 1974,1979, 1987). Resistance The following are some specific issues that create resistances in elderly patients undergoing sexual therapy. Many of the assign ments that are prescribed for older couples entail the wife’s taking a more active role in lovemaking, while the husband learns to accept a more passive or “receiving” position. Not surprisingly, such experiences and role shifts that have previously been avoided because they are threatening, often evoke intense anxiety and resis tance, despite the fact that on a cognitive level, the couple is given to understand that this is necessary if they are to remain sexually functional. The introduction of erotica or fantasy is another common source of resistance. Rejection-sensitive wives are often threatened by the therapist’s suggestion to their husbands that they “tune out” their performance anxieties and obsessions by focusing on a sexual
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fantasy. A woman who is emotionally fragile may be threatened if her partner desires anyone but her, often taking this as an indica tion that she is no longer desirable. In one such case, the wife’s persistent resistance to fantasy was an insurmountable obstacle to treatment. During the therapy sessions, she was repeatedly con fronted with the reality that her aging husband was merely trying to compensate for his physiological limitations. Treatment did not move forward until the wife gained insight into her transferential distortions, and came to realize that her husband’s need for erotica was not her father rejecting her all over again, but that her loving husband was simply trying to do his very best to sustain his erec tion so he would not dissappoint her. Not infrequently, the process of sexual therapy evokes latent marital hostilities that must also be resolved during the sessions if therapy is to succeed. The case mentioned above where the hus band’s passive-aggressive remark about his wife’s white pubic hair precipitated the couple’s sexual avoidance serves to illustrate this point. These spouses were initially too angry at each other to be able to commit themselves to or benefit from sexual assignments that were meant to heighten their enjoyment together. It was neces sary first, in the conjoint sessions, to confront this couple’s hidden power struggles, and to resolve their intense anger toward each other before they were able to stop sabotaging and to respond to sexual therapy. MAINTAINING SEXUAL FUNCTIONING IN MATURITY It is important for clinicians to realize that asexuality is not a normal part of the aging process. Doctors and therapists should not dismiss their mature patients’ sexual complaints as unavoid able aspects of aging, because, thanks to the recent advances in sexual medicine and the development of psychosexual therapy methods especially geared to this population, sexual functioning can be restored or materially improved in a high proportion of elderly patients. The prognosis is especially good for couples who had enjoyed a good sexual relationship prior to the onset o f agerelated changes in their sexual functioning. In addition, an avoidance o f intimacy and an inability to com municate effectively are frequently central issues in the dynamics of the sexual problems of the elderly. Therefore the improvement of the couple’s" emotional closeness and o f their communication
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with each other is a major focus of treatment in many cases. When this is successful, and it often is, the process of conjoint psychosexual therapy can result in a long-lasting improvement in the couple’s relationship, which is a most welcome extra benefit above and beyond the reconstruction of their sexual functioning. Although it is widely believed that sex no longer matters after middle age, the opposite is true, and sex often becomes more and not less important as a person grows older. Because sex is among the last pleasure-giving biological processes to deteriorate, it is potentially an enduring source o f gratification at a time when these are becoming fewer and fewer, and a link to the joys of youth. These are important ingredients in the elderly person’s emo tional and physical well-being. The aging process entails the acceptance o f many losses, losses of physical ability and health, o f power, o f social importance, often o f money, and so on. But if a 70-year-old woman can still excite her husband, and if she can still experience sexual pleasure and orgasm, she is less likely to feel that she has lost everything, including her sexual powers, and that she is now an old lady whom nobody wants. If she can maintain a sexual connection with her partner, she is apt to feel good about herself, even if she has a little arthritis, even if she has had to give up skiing, and even if the kids don’t call all that often, and she will be moved to make the effort to take care of herself and to remain attractive to her husband. Her retired husband might feel less lost and emotionally impotent, although he no longer has an attentive staff to do his bidding, although he has presbyopia and a hearing loss, and even if he can no longer win the tennis trophy, if he can still give pleasure to and “make it” with an attractive woman. The maintenance of sexual functioning in the elderly is also very worthwhile from a broader clinical perspective, because the pre mature loss of sexual functioning can contribute to emotional and physical deterioration in older persons. References Brecher, E. M ., and the Editors o f Consumer Reports Books (1984), Love, Sex and Aging, Little, Brown & C o., Boston. George, L. K., and Weiler, S. J. (1981), Sexuality in middle and late life, Arch. Gen. Psychiat., 3 8 , 919-923. Kaplan, H. S. (1974), The New Sex Therapy, Brunner/Mazel, New York. Kaplan, H . S. (1979), Disorders o f Sexual Desire, Brunner/Mazel, New York.
SEX, INTIMACY, AND AGING 205 Kaplan, H. S. (1983), The Evaluation o f Sexual Disorders: Psychological and Medical Aspects, Brunner/Mazel, New York. Kaplan, H . S. (1987), Sexual Aversion, Sexual Phobias, and Panic Disorder, Brunner/Ma zel, New York. Kinsey, A . C ., Pomeroy, W. B., and Martin, C. E. (1948), Sexual Behavior in the Human Male, W. B. Saunders, Philadelphia. Kinsey, A . C ., Pomeroy, W. B., and Martin, C. E. (1953), Sexual Behavior in the Human Female, W. B. Saunders, Philadelphia. Masters, W. B., and Johnson, V. E. (1966), The Human Sexual Response, Little, Brown and C o., Boston. Masters, W. B., and Johnson, V. E. (1970), Human Sexual Inadequacy, Little, Brown and C o., Boston. Palmore, E. (Ed.) (1970), Normal Aging, Duke University Press, Durham, NC. Palmore, E. (Ed.) (1974), Normal Aging II, Duke University Press, Durham, NC. Starr, B. D ., and Weiner, M. B. (1981), The Starr-Weiner Report on Sex and Sexuality in the Mature Years, McGraw-Hill, New York. ' Todarello, O ., and Boscia, F. M. (1985), Sexuality in aging: A study o f a group o f 300 elderly men and women, J. Endocrinol. Invest., 8 (Suppl. 2), 123-129. Wagner, G., and Green, R. (1983), Impotence, Plenum Press, New York. Weizman, R ., and Hart, J. (1987), Sexual behavior in healthy married elderly men, Arch. Sex. Behav., 1 6 , 39-44.
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