Later-life sex

It's not just in recent movies like "Hope Springs" and "The Best Exotic Marigold Hotel" that older people are actively seeking out better sex and new sexual partners. Although some psychologists may assume their oldest clients no longer have sex, research confirms that plenty of older adults are still interested and engaging in sex.

Between 20 and 30 percent of men and women in a nationally representative sample of Americans over age 50 remained sexually active well into their 80s, found a study published in 2010 in the Journal of Sexual Medicine.

Other researchers have found that older people are generally happy with their sex lives. In a 2012 study of women age 40 to 99 published in the American Journal of Medicine, for example, 61 percent reported being satisfied with their sex lives, regardless of whether they had a sex partner or even sexual activity.

In fact, satisfaction increased with age: The oldest women in the study were nearly twice as likely as the youngest participants to report being "very satisfied" with their sex lives. And the oldest and youngest women were equally satisfied with their ability to reach orgasm.

Working with other health-care professionals and using psychoeducation, cognitive behavioral therapy and other techniques to supplement medical approaches, psychologists are helping ensure that people continue to have healthy, safe and satisfying sex lives regardless of their age. They're helping older people overcome erectile dysfunction, menopause symptoms and other potential barriers to satisfying sex. And they're guiding survivors of prostate cancer, breast cancer and other conditions that often accompany aging in efforts to regain their sexuality.

Assessing older people's sex lives

Many psychologists and other health-care professionals, however, miss an opportunity to help older patients improve their sex lives — simply because they don't ask, says Maggie L. Syme, PhD, a research psychologist for the San Diego State University/University of California San Diego Cancer Center Comprehensive Partnership.

"They may be afraid of opening a Pandora's box — that by asking about sex, all this stuff will spill out that they won't know what to do with," says Syme, adding that few psychologists receive training about sex, let alone sex among older adults. "Some are embarrassed or don't want to embarrass their patients."

But asking questions about older patients' sexuality is critical. Sex is important to older people's overall quality of life, says Syme. Many of the barriers to successful older sexuality — such as erectile dysfunction or painful intercourse — can be overcome with the right help. And because many older people no longer need to worry about birth control and grew up before sex ed in school became the norm, they may not know how or even that it's important to protect themselves from HIV and other sexually transmitted infections — a growing problem among older people, says Syme.

She and colleagues have developed an assessment tool to guide psychologists and other practitioners through the process of asking such questions. Described in a chapter of the "Handbook of Assessment in Clinical Gerontology" (Academic Press, 2010), the tool includes questions on such topics as sexual history, activities, goals and desires, sexual safety practices and physical conditions that might affect patients' sex lives. Normalizing the assessment is key, says Syme, suggesting that psychologists tell older patients, "This is something I talk to all my patients about."

Psychologists should focus on more than just dysfunction, Syme adds. They should also ask about patients' satisfying sexual experiences, aspirations and use of "enhancement products."

"One thing we don't do well in our profession is talk about sexual enhancement and well-being," she says.

Overcoming challenges

Of course, psychologists also have an important role to play in helping those who do have problems.

Sometimes those challenges are psychological, such as libido-dulling depression or distress over a changing body.

Simply educating people about what's normal and what's not can help, says Jennifer L. Hillman, PhD, author of "Sexuality and Aging: Clinical Perspectives" (Springer, 2012) and a psychology professor at Pennsylvania State University's Berks College.

An older woman may be distressed because she believes her partner's erectile dysfunction is a sign that he no longer finds her attractive, for instance. "In the 50s and 60s, you start to see a longer time needed for physiological arousal, and typically, erections aren't as long-lasting or as rigid," says Hillman. "As a therapist, you can reinforce that this is just a normal change."

Psychologists can also help with physical concerns. After menopause, for example, many women experience vaginal dryness that results in discomfort or pain during intercourse. "[Pain] is not, and should not be considered, normal," Hillman emphasizes. "Yet very rarely do gynecologists or other health-care providers talk about different ways that it can be addressed."

And when they do, they are often off course, adds Hillman. Physicians, for example, may recommend K-Y Jelly, a lubricant that can exacerbate the problem because it is water-based and dries quickly. Instead, psychologists can recommend silicone-based lubricants or water-based products that don't contain glycerin.

Physicians may also overlook the risk of HIV and other sexually transmitted infections in older people in general but especially among lesbian, gay, bisexual and transgender older people, says Hillman.

Because of the "triple jeopardy" of age, gender and sexual orientation, older lesbians are especially at risk, she says. There's a common myth that older lesbians are immune from sexually transmitted diseases, for example. But almost half of older lesbians have had heterosexual intercourse at some point and 20 percent of those who haven't nonetheless have the human papillomavirus, the primary cause of cervical cancer, says Hillman, adding that female-to-female transmission of HIV is also rare but possible. As a result, she says, "health-care providers and therapists need to be attentive to older lesbians' sexual as well as general physical and mental health issues." In addition to addressing psychological issues and supplementing the information physicians provide, psychologists can also offer interventions. These might include alerting women and their partners that lubrication takes longer in postmenopausal women, teaching relaxation exercises that can reduce women's anxiety about painful intercourse and thus allow more effective lubrication, and suggesting that women masturbate as a way of increasing their lubrication over time. "Therapists can work carefully with their female clients to discuss any cultural, religious or individual concerns or fears about masturbation," says Hillman. "Some women report that if they have a ‘prescription' from their health-care professional to engage in masturbation, it becomes significantly less threatening."

Similarly, physicians may prescribe Viagra or Cialis to men without considering the effect on their female partners. "There can be vaginal trauma if a woman suddenly engages in sexual intercourse when she hasn't engaged in it in a few years," Hillman says. "Very rarely does the health-care provider speak to the partner."

Psychologists can offer practical tips as well as education, says Hillman. That might mean suggesting that patients with arthritis take warm showers and painkillers before sexual activity or that partners try new positions if one has had a stroke. Psychologists can also offer cognitive-behavioral interventions. To minimize "catastrophizing" — the tendency to predict the worst outcome for any given situation — psychologists can help patients examine their predictions more logically, predict more realistic outcomes, plan ahead for perceived barriers to success and even role-play possible scenarios. Other cognitive-behavioral interventions include guided imagery and exercises that shift the focus from orgasm to a more comprehensive sensory experience.

Managing patients' expectations is another important role for psychologists, says Barry McCarthy, PhD, co-author of "Coping with Erectile Dysfunction: How to Regain Confidence and Enjoy Great Sex" (New Harbinger, 2004) and a psychology professor at American University.

Men often believe that they can cure erectile dysfunction by popping a pill, for example. But Viagra and Cialis aren't always helpful, says McCarthy. "There has been a real overpromising about what the pill can do," he says.

While people often think the pills will restore the same easy erections men had in their adolescence, he says, the reality is that the pills only help men maintain erections once they're aroused. Anxiety can interfere with that process — something that relaxation and mindfulness skills can help prevent. Psychologists can also help couples learn how to integrate pills — or other medical interventions like penile injections — into their sex lives.

"The single most important psychosexual skill is not to transition to intercourse as soon as he gets an erection," says McCarthy. "He's afraid he'll lose the erection, but the time to transition to intercourse is when there's a high level of erotic flow."

Psychologists can also help patients understand that sex can mean much more than intercourse, McCarthy adds. Instead of panicking or apologizing if intercourse doesn't happen — both real turn-offs, he says — couples should get comfortable with what he calls "erotic, non-intercourse sex."

"The notion is that sex is much more than intercourse," he says. "That's a core concept."

Coping after cancer

Cancer brings its own set of challenges.

"There are now 13 million cancer survivors in the United States," says Leslie R. Schover, PhD, a professor of behavioral science at the University of Texas MD Anderson Cancer Center in Houston. And many of the types of cancer that have the best survival rates — bladder, prostate, gynecological, breast and colorectal cancer — also have a high prevalence of post-treatment sexual problems, she says.

Take prostate cancer, for example. By the time men develop the disease, says Schover, many have already given up sex because of erectile dysfunction brought on by hypertension, obesity and other cardiovascular issues common in older men. But for those who haven't, treating the cancer can itself result in problems. "Men are often given an overly rosy idea of how likely they are to retain or recover good erections," says Schover.

The incontinence that can also result from a prostatectomy is another issue that often goes undiscussed, she says. Even if survivors don't have to wear pads during the day, she explains, many leak urine when they get aroused or have an orgasm, creating problems for both partners. "Partners are reluctant to say how they feel about it, but it bothers them," says Schover. "If they used to have oral sex, they may stop without discussing why."

For gay men, prostate cancer treatment can bring additional concerns. For one thing, says Schover, you need a firmer erection for anal intercourse. "Some men also say that having a prostate adds to their pleasure during anal sex," she adds. "And the loss of semen, which happens after a radical prostatectomy removes the glands that make semen, can be a loss in terms of sensuality."

Psychologists can help men and couples with what Schover calls "sexual rehabilitation" following cancer treatment.

In a study published this year in Cancer, Schover and colleagues found that an online sexual counseling program for prostate cancer survivors and their partners worked just as well as a face-to-face format. Plus, says Schover, improvements in sexual functioning were still apparent after a year. Schover and her colleagues are also developing a computerized intervention to address women's loss of desire, vaginal dryness and other sexual problems post-cancer.

"There's a real shortage of people who are cross-trained to treat sexual dysfunction and the emotional aspects of chronic illness or cancer," says Schover. "They tend to be at major cancer centers, which is one of the reasons I've been working on Web-based interventions."

No matter what causes sexual problems in older people, say Schover and other experts, it's important for psychologists to counter what's often an over-reliance on purely medical fixes.

"There's definitely a medicalization of sexuality and aging," says Hillman. "The best thing is to have a tandem approach, with medical and psychological approaches; if you have one without the other, you can run into some significant challenges."

For more information, see the "APA Aging and Human Sexuality Resource Guide".

Rebecca A. Clay is a writer in Washington, D.C.