Sexuality and Quality of Life in Aging:

Implications for Practice

Terry Mahan Buttaro, PhD, APRN, Rebecca Koeniger-Donohue, PhD, APRN,
and Joellen Hawkins, PhD, RNC
ABSTRACT

Sexual activity continues into the 8th decade for many elders. This topic is neglected
in health care because conversations about sexuality can be difcult for health care
providers. Age, culture, sexual orientation, patient comorbidity, and time constraints
can impede discussions about sexuality. Additionally, sexual concerns of men and
women are often divergent. Men are likely to focus on performance, whereas women
may care more about cuddling, caring, and love. Knowledge of an older adults sexual
concerns is an important consideration for nurse practitioners. Information about
medications and sexual aids that can improve sexual health will increase provider
comfort in addressing sexual difculties.
Keywords: elders, sexuality
2014 Elsevier, Inc. All rights reserved.

he importance of sexuality for men and

women as a component of emotional and
physical intimacy is evident in the literature on
quality of life for healthy aging but remains a topic that
is uncomfortable to discuss for both patients and health
care professionals. The majority of authors in the
nursing literature discussed the problem of sexuality in
nursing homesthe scenario of the older male patient
entering the room of a female patient. The focus of
these articles is on how nurses can manage this problem, but no single article addresses discussing sexuality
with older adults who are essentially healthy, able to
live independently, and seek health and wellness care
in ambulatory care settings.
In the recent medical literature, a number of authors reported on surveys of sexual desire, attitudes,
behaviors, and function in older women and men.
Only 2 articles addressed how seniors can continue to
enjoy a healthy sex life, and none of the published
authors are nurse practitioners (NPs). The purpose
of this article is to discuss prescriptive and herbal

Readers may receive 0.83 continuing education contact hours, including

0.27 contact hours of pharmacology credit, approved by the American
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therapies that older patients may be using to augment

sexual health, as well as potential barriers to conversations about sexuality in aging.
LITERATURE REVIEW

Lindau et al,1 in a study published in the New England

Journal of Medicine, reported on a survey of 3005 respondents ages 57-85 who were queried as to prevalence
of sexual activity, behaviors, and problems. The prevalence of sexual activity in this sample was 74.8%. Reported sexual activity declined with age; it was 73% for
57- to 64-year-olds, 53% for those 65-74 years old, and
26% for those 75-85 years old. Women were much less
likely to report being sexually active than men. Half of
the women and half of the men reported at least 1
bothersome sexual problem and were concerned about
the impact of aging changes on sexuality. After the age of
50, 38% of the men and 22% of the women had discussed
sex with a physician. Womens most prevalent problems
were a lack of desire, difculty with vaginal lubrication,
and inability to experience orgasm. Older mens sexual
concerns were focused primarily on erectile difculties.
Those elders in poor health were less likely to be sexually
active and more likely to experience sexual problems.
DeLamater and Moorman2 reported on the Modern Maturity Sexuality Survey conducted by the
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American Association of Retired Persons in 1999. In

2013, Northrup et al3 repeated the survey. Among the
survey respondents, all 50 years or older, 59% of men
and 56% of women reported that their partners were
not fullling their needs. More than a quarter of the
men said they are not having enough sex, and a quarter
of the women reported not having the lifestyle they
had hoped for. Thirty-one percent of couples have sex
several times a week, 28% a couple times a month, 8%
once a month, and 33% rarely or never. The happiest
couples say I love you at least once a week. Interestingly, 90% of men and only 58% of women regularly say I love you to their partners.
A number of authors have reported on surveys
of sexual desire, attitudes, behaviors, and function
in older women and men. Ginsberg et al4 studied a
sample of 166 lower-income older adults living in
subsidized independent living facilities. Most of the 166
participants had physical sexual experiences, such as
touching, kissing, holding hands, and hugging, ranging
from daily to once a month. The majority did not want
to engage in sexual experiences, such as masturbating,
stroking, and intercourse, attributing their avoidance to
lack of a partner, age, and lack of interest.
Gott and Hinchliff5 elicited data on attitudes
toward and the value of sex in later life from men
(n 21) and women (n 23) ages 50-92 using the
World Health Organization Quality of Life Importance Scale and semistructured interviews. These
investigators reported that elders with a current
partner rated sex as having at least some importance
in their lives, whereas those without a partner rated
sex as having no importance. Barriers to being sexually
active meant placing less importance on sex.
THE EFFECT OF AGING CHANGES ON SEXUALITY

For most people, age-related changes begin in midlife

(around age 45) and increase over time. The physiological changes are multifactorial and can be related to
diminished blood ow and hormonal and neurologic
changes. In men, testosterone and estrogen levels start
to decrease just about the same time that women
experience menopause and a concomitant decrease in
circulating androgens and estrogen.6 This decrease in
hormones affects muscle strength, integument, bone
mass, and inammatory processes, as well as sexual
functioning for both men and women. Thus, men may
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begin to experience erectile dysfunction, and women

may experience urogenital atrophy. However, other
factors also impact sexual health as individuals age. In
both men and women, obesity, lack of exercise, hypertension, diabetes, atherosclerosis, incontinence,
alcohol, drugs, smoking, and psychological issues are
risk factors for sexual dysfunction.
SEXUAL HEALTH INQUIRY IN PRIMARY CARE

Health care practitioners are mandated to obtain a

complete health history from patientsboth yearly and
when a new patient presents to the practice. The health
history includes a thorough review of systems, including
a comprehensive sexual and reproductive history.
Younger women are most likely to be asked about safer
sex practices, menstrual cycles, last normal menstrual
period, dysfunctional vaginal bleeding, abnormal
discharge, number of sexual partners/preferences,
obstetrical history, family history, social history, and
habits. Young men are also asked about risky behaviors,
penile discharge, lesions, sexual history, and partners.
As patients grow older and their comorbidities increase, providers can conceivably overlook the sexual
history, perhaps because chronic health problems take
precedence during a visit. Other factors also impede
opportunities to include important sexual history information. Providers may feel pressed for time, but it is
also possible that clinical guideline changes decrease
opportunities for providers to discuss sexual health with
older adults.7,8 For example, routine Pap smears are not
recommended for women over age 65, and now men
over age 55 do not necessarily receive yearly prostatespecic antigen testing.7,8 Instead, men are encouraged
to discuss the risks and benets of routine prostatespecic antigen testing with their health care provider.8
Additionally, it is possible that there are barriers
to provider-patient discussions about sexuality in aging.
Despite the sexual revolution associated with the baby
boomer generation, cultural restraints and embarrassment discussing sex may prevent patients from talking
about sexuality with their providers,9 who also may feel
uncomfortable discussing sex with older adults.
It is also possible that content-laden curriculums
in medical schools and graduate nursing programs
may not include information about how to approach
this topic with patients. Lindau et al10 developed and
tested a scale to measure nurses knowledge and
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481

attitudes toward aged sexuality with a sample of

nurses in 8 nursing homes in Holland. The result is
both a Dutch and a Flemish version of the scale. This
could be a useful instrument for similar studies with
samples of nurses and NPs in the United States and as
part of educational programs for NPs on addressing
issues about sexuality that patients raise.
Block et al11 addressed how seniors can enjoy a
healthy and mutually satisfying sex life. These authors
offered concrete advice on how seniors can continue
to enjoy sex, adapting to the challenges of their
bodies. Their recommendations include being open
to new ideas, trying different positions, varying times
of day, and incorporating sex toys into sex play.
SENIOR SEX: RECOMMENDATIONS FOR MEN

Because erectile dysfunction (ED) is associated with

medication side effects, diabetes, coronary artery disease, and other disorders, male patients should be
routinely screened for ED in the primary care setting to
determine potential causes. Although testosterone
replacement is indicated for men with primary or
secondary hypogonadism and documented low testosterone levels, it is not indicated for men with normal
testosterone levels.12 According to the American
Urological Association (AUA), testosterone is not
indicated for the treatment of ED in men with a normal
testosterone level.12 The American College of Physicians determined there was not enough evidence to
recommend or not recommend testosterone therapy
for ED.13 Recent studies also raise increased concerns
about testosterone therapy.14,15 These studies suggest
that men with a past history of cardiac disease seem to
have increased susceptibility for a cardiovascular event
causing the Food and Drug Administration (FDA) to
re-evaluate testosterones safety.
Sildenal (Viagra; Pzer, New York, NY) and
the other phosphodiesterase-5 enzyme (PDE5) inhibitors (tadalal [Cialis; Eli Lilly and Company,
Indianapolis, IN] and vardenal [Levitra; Bayer
AG, Leverkusen, Germany]) are recommended by
the AUA and approved by the FDA for ED. Avanal [Stendra; VIVUS, Mountain View, CA]) is
approved by the FDA. Avanal, tadalal, and vardenal can be prescribed for men over age 65, although
there are recommended dosing adjustments with
many medications and hepatic and renal drug dosing
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considerations. These medications are generally safe,

but it is important to note that the side effects of these
medications are potentially noteworthy. For
example, QT prolongation is a concern with vardenal and may be a problem when vardenal is
used in combination with other medications that
cause QT prolongation.12 Common side effects of
the PDE5 inhibitors include facial ushing, headache,
nasal congestion, and stomach upset.12 PDE5 inhibitors
should not be used if the patient is taking organic
nitrates, and hypotension is a risk when they are used
in combination with alpha-blockers.12
The AUA also approves alprostadil intraurethral
suppositories for ED.12 These suppositories are
particularly effective for ED. However, they must
rst be used in the practitioners ofce because hypotension/syncope can occur.12
Films, literature, and a variety of devices designed
to increase sexual pleasure can help men overcome
difculties with achieving or maintaining an erection
and are available on the Internet. For example, penile
rings can help a man maintain an erection, and a
penile pump can help with achieving an erection.
The AUA ED guidelines approve vacuum erection
devices with a vacuum limiter for the safe treatment
of ED.12 Of note is that Medicare pays for penile
pumps (see www.medicareedpumps.com).
Although the FDA does not approve supplements, patients may ask about them. The American
Urological Association does not recommend yohimbine, an herbal stimulant used for ED as well
as a sexual stimulant used by women and men.13
Yohimbine is not FDA approved, although 1 small
study showed efcacy in orgasmic dysfunction.16
Yohimbine should not be used by patients who have
hepatic or renal dysfunction. Potential adverse effects
include arrhythmias, anxiety, irritability, bronchospasm, and even death.
A product from Thailand, called Butea Gel
(St. Botanica, Providence, RI; St herb, Pathumthani,
Thailand), stimulates an erection but is also used
as a stimulant for women. Butea superb, an herb
commonly used in Thailand as an aphrodisiac, is the
main ingredient. Additional sexual-enhancing ingredients in Butea Gel include Elephanttopus scabar
Linn, Betula aionoides Buch Ham, and Tinospora
Tuberculata Beumee.
Volume 10, Issue 7, July/August 2014

SENIOR SEX: RECOMMENDATIONS FOR WOMEN

Womens problems with sexuality as they age are also

both physical and psychological. The occurrence of
sexual dysfunction in all women has been estimated
at 25%-63%.17 Ambler et al,17 in a review of the
literature on sexual function in older women, noted
the paucity of studies and reported that the prevalence of sexual dysfunction may be as high as 68%86.5%. These authors provide an extensive discussion
of the possible physical and psychological factors
contributing to these estimates. The most common
problems for older women are lack of estrogen,
frequent lower urinary tract infections, problems
with arousal and achieving orgasm, lack of libido,
pain with intercourse, negative body image, and a
sense of diminished desirability and attractiveness.
According to Hillman,18 as women age, their
sexuality does not exist in a vacuum because it is
shaped signicantly by a variety of biological, psychological, social, and cultural factors, as well as environmental and institutional factors. Despite the fact
that the research body of knowledge on aging women
and the full expression of their sexual activity remain
underdeveloped, there is no empirical evidence that
women become asexual as they grow older.19,20
Hinchliff and Gott19 posited that cultural representations of aging and sexuality depict an inaccurate
picture for women in later life in which sexual activity
no longer assumes importance. This, despite the fact
that sexuality is deemed a vital aspect of healthy aging,
women rate sex as important or extremely important,
and sexual satisfaction is viewed as a component of
overall life satisfaction.19 Loe20 contended that sex is
still seen as mens territory, with women serving as silent
partners and that womens perspectives and opinions
are largely absent when it comes to the Viagra phenomenon as well. In addition, the dearth of populationbased data about representations of the sexuality of
older lesbian, gay, bisexual, transgender individuals is
notably missing in the literature.21 Thompson22
pointed out the frequent media and cultural heteronormative stigma in which the only kind of sexuality to be
valued and condoned is that among healthy heterosexual males. Acknowledgment of the linkage of these
factors is vital to examine and address the concerns and
needs of aging female adults. For example, an older
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wheelchair-bound amputee may be physically capable

of engaging in sexual behavior, but she elects not to
seek out a partner because of an internalized social
stigma that older women and physically disabled individuals, of any age or sex, are unattractive and asexual.
From a biological perspective after menopause,
vaginal dryness and atrophy can cause discomfort and
pain during intercourse. More frequent intercourse
and/or vaginal lubricants can be helpful in promoting vaginal lubrication, but many women may not be
aware that vaginal estrogen tablets, rings, or creams,
when appropriate, help signicantly in treating the
dyspareunia associated with menopause and the
vaginal dryness associated with chronic atrophic
vaginitis. Although there are no FDA-approved
products to aid female sexual dysfunction, 2 products
are described in the literature: Zestra (Semprae Laboratories, Innovus Pharmaceuticals, San Diego, CA)
and ArginMax (The Daily Wellness Company,
Honolulu, HI).23,24 The lubricant, Zestra, is a feminine arousal uid made from botanical oils designed
to stimulate nerves and blood vessels. Zestra creates a
warming sensation in the genital area and is effective
for women taking antidepressant medications and
women with sexual arousal disorder.23
The inability to experience orgasm is a common
side effect of selective serotonin reuptake inhibitor
antidepressants. This is because the serotonin boost
from these drugs decreases dopamine, which leads
to sexual problems. It can be benecial to switch
women to bupropion hydrochloride, an antidepressant that does not affect serotonin levels, enhances
dopamine function, and improves desire.
For older women patients having trouble reaching
orgasm, the amino acid L-argingine (ArginMax) is
an available herbal product that can be used by men
and women.25 Like Viagra, this naturally occurring
amino acid increases the production of nitric oxide,
a chemical released by the genital nerves during
arousal, delivering increased blood ow to the
area. The recommended dose is 1,000-3,000 mg
L-arginine supplement (available over the counter)
just before intercourse.26
The Aphrodite study27 did show that testosterone
therapy was efcacious for women with decreased libido, and authors of the North American Menopause
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483

Society28 Position Statement of 2005 discussed testosterone and estrogen therapy as options for postmenopausal women with diminished sexual desire. In
2013, Grossman and Polan29 also discussed the risks
and benets of testosterone therapy and intravaginal
dehydroepiandrosterone in the treatment of hypoactive sexual desire disorder in women but noted the
continued lack of FDA approval for these therapies.
Ospemifene (Osphena; Shionogi & Co., Florham
Park, NJ) is a selective estrogen receptor modulator
recently approved for the treatment of dypareunia in
postmenopausal women with vulvar vaginal atrophy.
However, there are potential concerns with ospemifene. It should not be prescribed for women with
hormone-regulated cancers (ie, breast cancers); may
cause endometrial hyperplasia; and, like other selective estrogen receptor modulators, there is a risk of
thrombotic events.30
SEXUALLY TRANSMITTED DISEASES IN OLDER
ADULTS

It is essential that NPs counsel older sexually active

women and men that age is not a barrier to sexually
transmitted infections, including human immunodeciency virus (HIV)/AIDS. Surprisingly, the incidence
of sexually transmitted diseases, including HIV/AIDS,
is growing faster among people over the age of 50
than any other age group.31 The Centers for Disease
Control and Prevention (CDC)32 in the US estimated
that 24% of AIDS infections in the US in 2011 occurred in people aged 50 years and older. The CDC33
recommendations specify routine testing for persons
up to age 64. However, according to the CDC, persons 64 and older should be counseled to receive HIV
testing if they have risk factors for HIV infection.32
Making testing routine for older persons can provide
an opportunity for the practitioner and older person
to discuss risky sexual behaviors.34 Thus, it is prudent
practice for the NP to consider that older adults are
vulnerable to a late or missed diagnosis of HIV/AIDS
and poorer treatment outcomes because of the misconception that they are not an at-risk population.
Asking about frequency or nonuse of condoms is
important because it is typical for this age group to
view condom use primarily as a means of contraception.35 Awareness of HIV as a possible differential
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diagnosis in older adults is also important for NPs to

keep in mind.
SUMMARY

The rst step in improving sexual health for older

adults is recognizing that sexuality is an important
consideration for many elders. From an NP perspective, the most critical aspect to consider in optimizing the sexual health of the older patient is to ask
about it. Applying Hillmans theoretical perspectives
can guide the NP clinician in assessing sexuality from
a holistic perspective18 (ie, looking at biological,
psychological, social, cultural factors, environmental,
and institutional factors that may be contributing to
any sexual concerns or difculties). NPs must also
acknowledge the barriers and biases that impede
conversations about sexuality and consider how best
to openly discuss sexual issues and safe sex practices
with patients. Including sexual questions in the health
history and review of systems will help identify patient concerns and factors impacting sexual health.
The NP role offers the opportunity to assist older
adults in being sexually creative and expanding patients
understanding that there is more to a satisfying relationship than the purely genital approach.
A loving relationship includes encouragement of couples intimacy, sensuality, companionship, and friendship, as well helping individuals understand the effects
that health, illness, medications, and treatments can have
on sexual functioning. Sexual health counseling for
older individuals requires a positive and respectful
approach to sexuality and sexual relationships as well as
the possibility of having pleasurable and safe sexual experiences, without any fear of coercion, discrimination,
or intimate partner violence. For optimal sexual health
to be achieved and maintained, the sexual rights of all
people must be respected, protected, and fullled.36
Amens37 research supports the position that
thoughtful sexual activity with a committed partner
improves well-being by enhancing longevity, immune
system function, joy, pain management, and sexual
health. He also posited that sexual activity may be a
preventive measure against the 2 leading causes of
death in the US, heart disease and cancer.37(p10)
Knowledge about herbal and prescribed medications that may aid a diminished libido and ED is
Volume 10, Issue 7, July/August 2014

important for all health care providers. However, the

lack of FDA approval and concerns about safety,
comorbidities, and polypharmacy in older adults
limits both prescriptive and over-the-counter options
for this problem. Knowledge of sex aids can be useful
in counseling patients and their partners. If the topic
is too sensitive to discuss, having an informational
handout of resources may be a discrete way of
imparting knowledge to your patients.
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4. Ginsberg TB, Pomerantz SC, Kramer-Feeley V. Sexuality in older adults:
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24. Ito TY, Trant AS, Polan ML. A double-blind placebo-controlled study of
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Terry Mahan Buttaro, PhD, APRN, is an assistant clinical

professor at the University of Massachusetts College of Nursing
and Health Sciences in Boston, MA, and can be reached at
terry.buttaro@umb.edu. Rebecca Koeniger-Donohue, PhD,
APRN, is a professor of nursing practice at Simmons College
School of Nursing and Health Studies in Boston, MA. Joellen
Hawkins, PhD, RNC, is professor emeritus at Boston College
and writer-in-residence at Simmons College School of Nursing
and Health Sciences. In compliance with national ethical
guidelines, the authors report no relationships with business or
industry that would pose a conict of interest.
1555-4155/14/$ see front matter
2014 Elsevier, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nurpra.2014.04.008

Readers may receive 0.83 CE contact hours,

including 0.27 contact hours of pharmacology
credit, offered by AANP, by completing the
online posttest and evaluation at
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485