1. Ageing & Intimacy: Sexuality in later life. Dr Allyson Waite
Ageing & Intimacy: Sexuality in later life Dr Allyson Waite Registered Clinical Psychologist Co-Director Sex Therapy New Zealand

2. Programme Background Myths and Reality of Ageing
Intimacy & Sexuality in later life
Biological factors and sexual function
Psychosocial factors and sexual function
Coping with change
Dementia and sexuality
Raising the issue

3. Preparation to be Sexual
What sex education did you receive as you grew up?
How well did this prepare you for
becoming a sexual being?
dealing with sexual concerns as a professional now?

5. Myths of Ageing & Sexuality
You have to be beautiful to be desirable.
You have to be young to have sex.
You have to have a partner to have sex.
If you’re widowed it’s the end of your sex life.
Older people should be looking after their grandchildren.
Older people can’t change.
Ageing and sexual dysfunction are inevitably linked.
Mixed messages – all in the mind/all decline
Derogatory terms – expressing sexuality

6. The Reality of Ageing Biological changes – impact on sexual function.
Chronic illness or disability; medications.
Losses:
role, function, significant attachments & relationships (bereavement/divorce), identity, income (retirement)
Women outlive men (approx 7 years)
Unresolved past issues – trauma; attachment needs
Life stage issues - Erikson
Traditional beliefs and values tested
Anxiety – dependence, disease, death.
Diversity

7. Domains of Intimacy Psychological Emotional Physical Operational
Social
Spiritual

8. Health Benefits of Sexual Expression Mitchell,S. & Owens, A. F. (Eds)
Raising self esteem
Recharging batteries
Repair relationship distance/damage
Rise in oxytocin
Lower cancer risk
Improved immunity
Improved fertility
Decreased vaginal atrophy and increased testosterone
Lower mortality
Analgesic effect

9. How important is sex in later life. The view of older people. (Gott, M
How important is sex in later life? The view of older people (Gott, M. & Hinchliff, S., 2003)
All with current sexual partner - some importance
Those rating greatest importance - context of emotional intimacy in their relationship as a whole
Those rating sex not particularly important - not in a sexual relationship/partnership
Minority - sex more pleasurable/greater importance with age
Experiencing barriers to being sexually active: (e.g. no partner or partner’s health problems) – some reprioritised importance of sex
Importance of non sexual touching to maintain physical intimacy

10. Sex for the Mature Adult Weeks, D.J. SRT 17/3, 2002
Need to challenge myths re ageing and sexual dysfunction
Physiological changes exceeded by psychological, emotional issues and ageist beliefs
No fixed biological limit to a satisfactory sex life during old age.
Correlation with sexual activity and enjoyment before, during and after middle years.
More > less sexual activity related to increased sexual satisfaction within a relationship
Association between psychological health and sexual pleasure.
Sexual satisfaction - major contributor to quality of life, maintaining self esteem & good self concept.
Most prevalent problems partner/relationship
related, lack of tenderness, partner problems

11. Sex & Nursing Home Care Lack of partner Lack of privacy
Lack of opportunity
Attitudes of staff
Chronic illness
Dementia and urinary incontinence.
Loss of interest
Loss of feelings of attractiveness

12. Biological Variables Impacting on Sexual Functioning in Older People.
Physiological changes – sexual function
Illness, disability, pain
Medical and surgical interventions
Medications
Tiredness, stress
Obesity

13. The Couple Sharing Long Term Illness
(2004) d’Ardenne
Physical and psychological effects of illness – for both partners
When one becomes caregiver, the other dependent - nature of intimacy changes.
Caregiver may have to provide personal care
May lose free time and income; social isolation.
May have stress of watching suffering.
May be grieving ‘loss’ of companion.
May have huge frustration.

14. Psycho/social variables Impacting on Sexual Functioning in Older People.
Partner related problems
Relationship issues
Past traumatic sexual experiences
Unresolved emotional experiences
Self esteem, body image
Lack of education, knowledge
Social expectations/sexual culture

15. Coping with change and maintaining intimacy
Open communication
Acknowledging losses/changes - self/partner/relationship
Grief work
Changing expectations - rescripting – sex/intercourse
Broadening concept of sex and intimacy
Problem solving
Maintaining non sexual touch
Understanding changes
Dealing with potential sources of pressure
Dealing with anxiety and rebuilding confidence
Dealing with past issues – emotionally/sexually

17. Impact of Dementia on Marital Relationships
Baikie (2002)
Majority of people with dementia live in community, often cared for by a spouse.
Relationships under these conditions require social support.
Carer stress
“Being neither a wife nor a widow”.
Loss of personality, not being recognised.
Demands on spouse:
Find a way to deal with their love of their partner
Deal with frustration, anger, grief etc.
Watch the devastating effects of the disease
Face the loss of their relationship
Assume major responsibility for care.
How spouse has experienced relationship before illness affects how they see role of caregiver now.
Partner has to change, person with dementia cannot.
Partner has to find a way to handle a sense of obligation to be sexual.

18. Aspects of Dementia which Challenge Intimacy
Verbal communication difficult.
Visual and hearing difficulties.
Complex tasks become more difficult.
Lack of initiative or withdrawal from usual activities.
Emotional and personality changes.
If fronto-temporal dementia:
Loss of the ability to empathise,
Behave inappropriately or in an uninhibited way,
Easily distracted.

19. Dementia’s Impact on Sexual Behaviours
Desire may decrease as a result of dementia
Desire may increase as a result of dementia.
They may be uninhibited - inappropriate
“Challenging behaviours” – carer stress
They may make unreasonable demands.
They may forget they recently had sex.
They may brood in response to refusals.
Co-ordination problems make caressing, penetration difficult.
They may forget to caress.

20. “Opening a can of worms…”
Barriers to managing sexual dysfunction in primary care:
Concerns about lack of knowledge, expertise, opening a floodgate, personal embarrassment, lack of time, sensitivity and complexity of issues, gender, culture, orientation
22 GP’s – how do they perceive and manage sexual health concerns of older people
Sexuality generally not proactively pursued – sexual health seen as related to younger people – e.g. STI’s and contraception, discomfort with raising with this generation and not wishing to cause offence
Barrier’s from patients – 45 patients – aged 50-92
Most saw GP as most appropriate person to approach. However, barriers included personal characteristics of the GP, shame embarrassment, fear of disapproval, judgement, attribution of problems to normal ageing,

21. PLISSIT Permission Limited Information Specific Suggestions
Intensive Therapy

22. What you can do to help
Open the door - “Its okay to talk to me about sex.”
Encourage to talk
Give information
Listen – under rated!
normalise
reassure
specific solutions – practical, PDE-5i’s, aids
Clarify expectations/fears
Differential diagnosis: disease/treatment side effect/psychogenic.
Know where to refer on when needed

23. Raising the Topic of Sex
Find an opportunity:
When discussing lifestyle issues
When prescribing medication
In a general checkup, review etc
Create an opportunity:
Generalising
Normalising
Link to a diagnosed condition
Use statistics

24. Where to from here? Referrals: Sex Therapy New Zealand (STNZ)
Further training:
The Good Fellow unit, University of Auckland
Resources:
Sexuality – key facts for men over 50
Sexuality – key facts for women over 50

26. References
Baikie, E. (2002) Impact of dementia on marital relationships., Sexual and Relationship Therapy 17, 3,
d’Ardenne, The Couple Sharing Long Term Illness. (2004) Sexual and Relationship Therapy, 19/3,
Gott, M. & Hinchcliff, S. (2003) Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people. Family Practice, 20,6,
Gott, M. & Hinchcliffe, S. (2003) How important is sex in later life? The views of older people. Social Science and Medicine, 56 (8)
Gott, M., Galena, E., Hinchcliff & Ellford, H. (2004) “Opening a can of worms:. GP and practice nurse barriers to talking about sexual health in primary care. Family Practice, 21, 5,
Gott, M., Hinchcliff, S. & Galena, E. (2004) General practitioner attitudes to discussing sexual health issues with older people. Social Science & Medicine 58,
Gott, M. (2005) Sexuality, Sexual Health & Ageing, Open University Press, New York
Hill, J., Bird, H & Thorpe, R. (2003) The effects of rheumatoid arthritis on sexual activity and relationships. Rheumatology, 24,
Trudel, G., Turgeon, L. & Piche, L. (2000) Marital and Sexual aspects of old age. Sexual and Relationship Therapy. 15, 4,
Watters. Y. & Boyd, T. (2009) Sexuality in later life: opportunity for reflection for health providers. Sexual and Relationship Therapy, 24, 3-4,
Weeks, D.J.,(2002) Sex for the Mature Adult: self esteem and countering ageist stereotypes, Sexual and Relationship Therapy, 17/3 ,

27. Assessment Sex Coaching for Physicians
Assessment Sex Coaching for Physicians. MA Perelman (2003) International Journal of Impotence Research 15,5.
The brief sex status exam:
Potential for cluster problems.
Personal distress.
Ask specific questions
Factors to look out for:
Lack of attraction or erotic energy.
Anxiety, anger, drug/alcohol effect.
Masturbation style, frequency & attitude.
Sexual expectations.
Get a comprehensive description of actual behaviour and cognitions: immediate, intermediate and remote causal layering.
GP’s can manage current obstacles to success (organic and psychogenic)-
Managing time crunch.

28. Treatment: general aspects (Perelman, 2003)
Modifying expectations.
Using drugs as a therapeutic probe.
Use follow-up to manage noncompliance and improve outcome:
schedule f/u appt day first prescribe
monitor side effect, assess success, alter dose if necessary,
ongoing education where necessary,
ensure compliance from patient and partner.
Bio psychosocial issues which can evoke non-compliance:
fear of complications
change associated with aging, chronic disease/injury
changes associated with medications
alcohol, smoking, life stressors
loss of partner,
partner’s attitude.
relapse prevention strategies.