It's not age that prevents sexual activity later in life.

OBJECTIVE: To describe key factors that facilitate sexual behaviour in later life.
METHODS: Re-analysis of data from a study of 2,374 Dutch older adults.
RESULTS: Partner availability, gender and health are likely to be more important factors influencing sexual behaviour engagement than the factor of age in later life. Lack of partner availability, traditional gender roles and poor health are associated with older age. However, current generations of older adults will be more capable, less ashamed of their sexual desires and engage in more sexual behaviour than prior generations.
CONCLUSION: This analysis observed that sexual activity is associated with partner availability and better health, rather than age, countering stereotypes of decline in sexual behaviour and normalising sexual activity and desire in later life.

Policy Impact

This manuscript demonstrates that partner availability, cultural differences towards engagement in sexuality between genders and health are likely to be more important factors influencing sexual behaviour engagement rather than the factor of age in later life. This concept provides opportunities for learning and normalises sexual activity and desire in later life.

Practice Impact

Health‐care professionals should incorporate sexual health in their routine care of older adults. By incorporating open discussion of sexuality and providing ‘safe sex’ information to older adults, health‐care professionals can help prevent the increasing rise in sexually transmitted diseases, increase adherence to medication and improve quality of life.

INTRODUCTION

What are your future expectations regarding sexuality in later life? Be careful, as research has shown that your expectations are likely to create a self‐fulfilling prophecy.1 Research suggests that those who believe that older people do not engage in sexual activity are less likely to engage in sexual activity themselves decades later when they are considered older adults.2 Take a moment to imagine a world without physical tenderness and sexual behaviour. I am not alluding to a futuristic sci‐fi film such as Demolition Man where forms of physical intimacy are viewed as an illegal and indulgent activity and have been replaced by a form of virtual reality. I am referring to your life, right now. There would be no hugs, handholding, massage, stroking or sexual activity. How would you cope with limited or no physical touch? Now consider that this is the reality for the majority of unpartnered older adults.

This manuscript aims to describe key factors that facilitate sexual behaviour in later life. Firstly, key terms are described. Secondly, data from a study of 2,374 Dutch older adults 3 are re‐examined to illustrate how culture and lifestyle, not age, are important for sexual behaviour in later life. Finally, findings are supplemented with literature on sexual behaviour in later life.

‘Sexual activity’ definition

Sexuality is regarded as an essential element of well‐being, happiness and quality of life across all adult age groups.4, 5 The World Health Organization views sexuality as ‘a central aspect of being human throughout life’ with sexual health as ‘a state of physical, emotional, mental and social well‐being related to sexuality; not merely the absence of disease, dysfunction or infirmity [page 5]’.6 Sexual activity is thus of interest beyond the reproductive years and an important aspect of active ageing. The World Health Organization's definitions do not focus on the lack of sexual activity or sexual function, but on continued engagement in sexual activity. While ‘sexual activity’ incorporates intercourse, it is clear that it can also encompass emotional intimacy, close companionship, flirting, affection, petting, hugging, kissing, desire and self‐pleasure. Physical touch, defined as skin‐to‐skin contact with another human,7 is another aspect of sexual activity. Physical touch can be with or without sexual intention; however, this manuscript focuses upon actions with an intended sexual component.

‘Older adult’ definition

The World Health Organization defines an older adult as a person aged 60 years or older.8 In wealthier countries, the definition of older adult tends to be related to retirement age, which is commonly 65 years of age. In Australia, retirement age is currently 65.5 years, and this will slowly increase to 67 years by 2023. While the majority of research to date uses 65 years or more as the definition of older adult, we are starting to see a trend in increasing this cut‐off to 70 years.

Populations are getting older

By 2050, just over one in five in the population will be aged 60 years or older.8 That is more than double the proportion in 2000.8 Every older person is different, some people will have the functioning of a 30 year old, while others will require full‐time assistance for basic needs.8 As a cohort, newer generations will have more functional ability than prior generations of older adults.9

In general, people are encountering health concerns later and are having more active years.9 The increase of roughly 1.5 years of ‘active ageing’ per decade 9 is not well understood by policymakers or the general population. The fact is that we are living longer than previous generations and are mentally, physically and sexually capable for longer.9 This demographic shift presents the challenge of supporting older people to maintain fulfilling, and preferably independent, lives for longer. Contemporary older adults should expect to engage in society and enjoy life for longer than previous generations.

Sexual activity among older adults

There is a common misconception that individuals become asexual as they get older.10, 11 This belief is held by both younger and older people.12 There is a diverse response to sexuality during the ageing process: some welcome diminished sexual desire, some have increased enjoyment in sexual activity, while others are situated between these two extremes.3 Overall we know that the broader aspects of sexual activity, such as affection, are more important than sexual intercourse to older adults,13 as is the case for some younger people.

Older adults are engaging in sexual activity and physical tenderness. As illustrated in a sample of 2,374 Dutch aged 65+ years (Figure 1), almost half of partnered older adults engaged in sexual activity within the past 6 months and the vast majority had physical tenderness in their lives.11 However, very few unpartnered older adults engaged in these behaviours, especially unpartnered women where only 1% were sexually active and 5% had physical tenderness in the past 6 months.

Figure 1

Age‐stratified percentage of older adults engaging in sexual activity or physical tenderness in the previous 6 months (n = 2,374). Information originally presented in Freak‐Poli et al.11 ‘y’ denotes ‘years’. ■ Sexual activity; Physical tenderness

After stratification by age group, Figure 1, engagement in physical tenderness and sexual activity does decrease slightly with increasing age, but the decrease is no comparison to being unpartnered.

PARTNER AVAILABILITY

As illustrated in Figure 1, the greatest barrier to being sexually active is not older age—it is lack of partner availability, and women are particularly disadvantaged.2, 10, 11, 14, 15 In the Dutch sample, partnered older adults were 15 times more likely to engage in sexual activity and 51 times more likely to engage in physical tenderness than unpartnered older adults.11 The fact that older partnered adults were engaging in sexual behaviour could lead to the theory that given the opportunity, these unpartnered older adults would also like to engage in sexual behaviour. In fact, a contemporary population‐based study of 5,059 rural South Africans reported that the prevalence rates for casual sex were similar for someone aged 45 and 80 years.16

While marital status has been discussed in terms of being a proxy for sexual partner availability, recent research has observed beneficial effects of intimate romantic relationships regardless of marital status.17 Many people experience changes in marital status over their life course,4, 18 and there is an increasing number of older adults who are not married nor cohabiting with their partner.10 Hence, partner status rather than marital status should be considered when studying sexual activity and physical tenderness.

Unpartnered older women

While both unpartnered older men and women are less likely to engage in sexual behaviour than partnered older adults, older women greatly outnumber older men. Figure 1 represents 675 unpartnered older women and 117 unpartnered older men, illustrating that there is roughly one older unpartnered men to every six older unpartnered women. (Beyoncé song reference).

On average, women live longer than men, and men tend to pair with younger women, resulting in women facing their husbands' ageing before their own.4, 11 Even if a woman is partnered, at 80 years of age she is vulnerable to the effects of the impotence found in approximately 30% of male partners,19 reducing her chance of having penetrative sex. While a healthy sexual relationship need not include penetrative sex and older married adults have reported that affection is more important,13 women who outlive their partners may not find a partner with whom to experience physical tenderness. Women spend approximately a decade in widowhood without a partner due to women living longer than men and men pairing with younger women.4, 11 As described by Rosen et al.5 ‘…interest in sex does not necessarily diminish or wane with age … reduction in sexual activity observed with increasing age in women was largely due to the unavailability of a sexual partner and not a lack of interest in sex [Page 293]’.

CULTURAL DIFFERENCES TOWARDS SEXUALITY BETWEEN GENDERS

Cultural factors further disadvantage adult women in our society. Although both women and men are implicated in the stereotype of the ‘asexual’ older person, the sexual double standard,20 does not end at maturity; older women tend to be subject to more restrictive sexual standards.21

Treatment of sexual dysfunction

It is claimed that sexual dysfunction is more prevalent in women than men.22 Nevertheless, medication to treat sexual dysfunction was first available for men's erectile dysfunction and continues to be mainly targeted at men,19, 23 who are more likely than women to take medication for sexual dysfunction,19, 23 discuss their sexuality,24 and engage in solo masturbation.10, 24 In the absence of data on whether older women (and men) are satisfied with their current experience of sexual intimacy and physical tenderness, we cannot make confident assumptions about whether women's circumstances require intervention. It is important not to assume either that an older person is not interested in sexual pleasure or that they are unhappy with not having a sexual partner11 and health practitioners should enquire.

Reporting bias

Prior research has identified measurement bias for sexual activity by gender: women may have a tendency to under‐report their sexual activity or physical tenderness, while men may be more likely to over‐report.11, 24 In a subsample of 152 opposite‐sex coupled older adults, it was observed that men were more likely to report sexual activity than women, while there was no difference in reporting of physical tenderness.11 It is possible that a gender difference for sexual activity, but not physical tenderness, may be observed if there was reporting bias arising from embarrassment, conformity with expectations of masculinity or a cultural sexual double standard.11 For example, as erections are analogous to masculinity,23 men may fear the stigma associated with being asexual. In contrast, the cultural emphasis on appearance and youth for femininity,10, 23 may make older women feel embarrassed for having sex at older age,2 especially if it is outside a socially accepted relationship.14 Additionally, sexuality can be a taboo or sensitive topic and unintentional information bias may occur given the usual generation gap between interviewer and interviewee.

HEALTH

Among the 2,374 Dutch sample aged 65 years or more, a number of demographic and health factors were associated with physical tenderness and sexual activity.11 Younger age was the most consistent factor associated with physical tenderness and sexual activity; however, some time is required to better understand the findings. The findings are presented in odds ratios (OR), where 1.0 represents no difference and less than 1.0 represents more engagement in the factor's reference group. Among males, not being a current bicycle rider is more strongly associated with not engaging in sexual activity (partnered: OR: 0.63, unpartnered: 0.03) than ageing 1 year (partnered: OR: 0.88, unpartnered: OR: 0.88) (Figure 2). Notably, bicycle riding was the only physical activity measure available in this Dutch sample. Hence, theoretically the advice could be to take up physical activity, potentially bicycle riding, and age 3 to 8 years—based on these statistics their sexual activity engagement could be the same. Similarly among partnered older adults, being a current smoker is more strongly associated with not engaging in physical tenderness (partnered males: OR: 0.43, partnered females: 0.54) than ageing 1 year (partnered males: OR: 0.92, partnered females: OR: 0.94). Hence, theoretically the advice could be to quit smoking and age 7 years—based on these statistics their physical tenderness engagement could be the same. So get a year older, quit smoking and start physical activity—engagement in physical tenderness and sexual activity may increase. While this is cross‐sectional data and causal inference cannot be drawn, the main point is that too much emphasis is being placed on ‘ageing’ and I am suggesting that lifestyle and other factors could be more important for engagement in sexual behaviour.

Figure 2

Examples of characteristics associated with sexual activity and physical tenderness in the past 6 months (n = 2,374). Information originally presented in Freak‐Poli et al.11 The findings are presented in odds ratios (OR), where 1.0 represents no difference and less than 1.0 represents more engagement in the factor's reference group. The reference group for ‘No bike’ is current bicycle rider without effort. The reference group for ‘Smoker’ is never smoked tobacco. age 1 yr = ageing by 1 year

A key message is that greater age may be associated with lower engagement in physical tenderness and sexual activity, because greater age is associated with worse health.25, 26 For example, no cognitive impairment was associated with more engagement in physical tenderness and sexual activity.27 As there was moderate to substantial agreement within a subsample of coupled adults who had one partner categorised with cognitive impairment, the limitations surrounding reporting bias by those with cognitive impairment were overcome.27 Hence, physical, mental and cognitive health may present a potential barrier to maintaining or instigating intimate relationships as we age. However, there are modifiable health factors that may help increase engagement in physical tenderness and sexual activity. Within the Dutch sample, modifiable health factors included not smoking, greater vegetable intake, lower waist circumference, bicycle riding and happiness.11, 26

CLINICAL IMPLICATIONS OF NOT ADDRESSING SEXUAL ACTIVITY IN LATER LIFE

In contrast to the World Health Organization's definition,6 a review of Australian sexual health policy found that ‘Existing policy has a focus on risk, not wellbeing, in relation to sexual health, and an emphasis on reproduction, which excludes midlife and older people [page 1 abstract]’.28

Direct implications for the health and well‐being

It is evident that sex is becoming increasingly important to older adults.2 The stereotyping of older adults as asexual has direct implications for the physical health and well‐being of older adults, including:

Both health professionals and older adults are not initiating conversations about sex.29, 30, 31 An American study found only 38% of men and 22% of women aged 50+ years reported having discussions concerning sex with their health practitioner.29 Similarly in Australia, this 20‐year‐old quote by Pitt31 is still, unfortunately, valid today ‘some older people are too shy to seek help, fearing that they should be ‘past it’ and may be regarded as ridiculous or as ‘a dirty old man’ (or woman) [page 1452]’.

There is limited testing for sexually transmissible infections among older people, resulting in a recent increase in infections.32 As older Australians are not considered a high‐risk group for sexually transmitted diseases, there are no policy recommendations surrounding testing of older adults.28, 33

Patients are discontinuing necessary prescribed medications because of adverse effects upon their sex lives.30 As examples, prescription of blood pressure,34 depression35 and seizure36 medications are common, have adverse side effects on sex and known non‐adherence due to increased sexual dysfunction.

There is a lack of knowledge that sexual issues are possible serious illness symptoms.30 Patients and health practitioners mistakenly attribute negative experiences of sexual life to age or a stage in life rather than a health issue.37 Sexual issues may actually be a warning sign or consequence of diabetes, systemic infection, urogenital tract conditions, depression or cancer.30

Patients may have unmet needs in terms of communication and counselling concerning sex after a serious illness.37

Undiagnosed or untreated sexual problems can lead to depression, anxiety, social withdrawal and other mental health issues.30

Reduction in sexual activity and physical tenderness is a potential barrier to maintaining or instigating intimate relationships. Lack of human touch is known to lead to feelings of isolation, anxiety, insecurity and decreased sensory awareness.7 Furthermore, touch plays an important role in communication, relationships and sharing of feelings.7, 38 Therefore, lack of physical touch may contribute to older adults receding socially, which is known to impact interpersonal relationships and health negatively.39 Research has suggested that there may be a link between lack of physical touch, sensory decline and cognitive decline.38

Addressing sexual activity among older adults can contribute to maintaining and improving well‐being and quality of life.4, 5

The benefits of touch

Research into the benefits of physical touch is most advanced in infant health. With media bylines such as ‘How Orphanages Kill Babies’, it is easy to understand the finding from a 12‐year study which compared children who were randomly assigned to foster care versus children who remained in six Romanian orphanages.40 Vanderwert et al40 observed that ‘a stable high quality caregiving environment [page 68 abstract]’ is necessary for infant healthy survival, with lack of physical touch and social interaction having psychological and fatal consequences. Furthermore, they found that negative physical touch such as abuse shrinks a child's brain and stunts development. Similarly, research into the high rates of preterm infant death in Cambodia observed that preterm infants who were held close to their parents thrived, especially when in contact for most of the day.41 This knowledge has been converted into the common practice of Kangaroo Care, where preterm infants are held skin to skin with parents for as long as possible, providing the infant with the greatest fighting chance for survival.42 To initiate change, the World Health Organization published a report in 2004 titled ‘The importance of caregiver‐child interactions for the survival and healthy development of young children’, outlining developmental aspects of child care including touch.43 However, the benefits of physical touch in regard to increasing resilience in ageing populations are underdeveloped.

Starting the conversation

It is evident that sex is becoming increasingly important to older adults. Australian research has identified that this group of the population is concerned about the lack of information and open discussion around sexual pleasure with ageing, particularly by health‐care professionals.31 Health‐care professionals can help prevent the increasing rise in sexually transmitted diseases among older adults by incorporating them into standard testing protocols and providing ‘safe sex’ information, which many older adults missed due to being married before the initiation of sex education.11

Offering an opportunity for open discussion regarding sexuality and medical assistance without imposing can be a difficult balance for health professionals. The PLISSIT44 (Permission, Limited Information, Specific Suggestions and Intensive Therapy) model is available to facilitate discussion and can be built into routine health screenings. Originally developed by a psychologist in 1976 for treatment of sexual issues, the PLISSIT model has now been extended to a range of subpopulations to address sexual health‐care needs.44 Additionally, the SexAT45 (Sexuality Assessment Tool) was specifically developed for residential aged care facilities, but information provided in the toolkit can be extended to community‐dwelling older adults. If a health professional feels uncomfortable or unequipped, there are opportunities for further education or patients can be offered referral to sexologists.

FUTURE GENERATIONS OF OLDER ADULTS

The social context has also changed due to generational differences. New generations of older adults are more extroverted,14 spend more time out of a marital relationship,2 are less ashamed of their sexual desires23 and engage in more sexual behaviour10, 14, 18 that is more varied.46 Baby boomers (defined as the birth cohort 1946‐1965) have begun to turn 70 years of age. Baby boomers are considered the advocates of the sexual revolution in the 1960s and 1970s, which pushed the boundaries of sexual expression and relationships.47, 48 There is evidence that some baby boomers who did not take part in the sexual revolution and followed the conventional expectation of heterosexual monogamous marriage are no longer conforming to those social role norms as older adults,48 while other baby boomers have continued their sexually adventurous behaviour.48

It is evident that sexuality is becoming increasingly important to older adults.2 Furthermore, Western culture and more liberated sexual views have influenced countries where it may previously have been considered dishonourable to discuss sexuality.15 The expectations associated with these changes may mean that new generations of older adults, including unpartnered women, experience greater distress from reduced sexual activity and physical tenderness associated with ageing. There is evidence to support this assertion. Women and men in their fifties and sixties are reporting that they masturbate49 and participate in diverse sexual experiences and relationships outside marital monogamy48; the generation following the adults in our sample may report different experiences and expectations of sex and intimacy as they age. Alternatively, the fact that older adults are more likely to engage in sexual activity outside of monogamous relationships48 and self‐pleasure through masturbation49 may provide greater opportunity for sexual behaviour engagement than prior generations of older adults.

LIMITATIONS

Apart from one study of four birth cohorts of non‐demented 70‐year‐olds spanning 30 years,14 there is very little research assessing sexual activity in later life over time. The vast majority of the research presented in this manuscript is from cross‐sectional surveys. Therefore, the direction of effect for the relation between sexual activity and health is uncertain. However, sexual activity is known to decrease with rapidly deteriorating health25 and sexual issues may actually be a warning sign or consequence of diabetes, systemic infection, urogenital tract conditions, depression or cancer. Hence, decreasing health is likely preceding decreases in engagement of sexual activity.

POLICY IMPLICATIONS

Older adults who are active and healthy are an asset to the social and economic fabric of their communities. Addressing the sexuality, and thereby improving health and well‐being, of older adults is aligned with Australia's National Priority Goal of ‘Ageing well, ageing productively’, ‘Strengthening Australia's social and economic fabric’, and ‘Building healthy and resilient communities throughout Australia by developing treatments, solutions and preventative strategies to improve physical and mental wellbeing.’ Addressing sexual activity among older adults is aligned with The Australian Social Inclusion Agenda which encourages the active participation of all Australians, and the World Health Organization's call for a new paradigm ‘towards an age‐friendly world’ which encourages participation and engagement of older people, rather than a focus on dependency and care.

As articulated by Kirkman et al,50 ‘A policy would enable preventative health measures. Clinical conversations would be easier and more likely to occur, leading to suitable interventions and health promotion. This in turn will reduce social and financial costs of burden‐of‐disease. Improved sexual health and better understanding of relationship diversity will increase the wellbeing of older people’ [page 17 abstract].

CONCLUSION

Partner availability, cultural differences towards engagement in sexuality between genders and health are likely to be more important factors influencing engagement in sexual activity than the factor of age in later life. As ‘Cultural norms around sex influence the choices that individuals are able to make [page 127]’,3 open discussion with adults about sexuality, unrestricted by assumptions about age or gender, should contribute to reducing stereotypes and taboos that limit older adults’ opportunities for sexual and tender physical experiences. While men are more likely to take medication for sexual dysfunction, discuss their sexuality and engage in solo masturbation than women, there is no reason for these gender differences at any adult age group. Changes in cultural attitude through open discussion of sexuality at all adult ages would likely improve sexuality for older people. It is important not to assume that an older person is not interested in sexual pleasure or that an older person is unhappy with not having a sexual partner.

Sexuality is an important aspect of active ageing. As sexuality is a lifelong experience, a deeper understanding of sexual health should be a priority across all age groups. Older people should be encouraged to seek help should they desire it. Policy that supports and promotes good relationships and sexual health specific to the needs of older adults is required.

I hope that this discussion paper will increase the understanding of sexual behaviour and physical tenderness in the ageing process, providing information for health‐care professionals and older adults themselves. Thinking of sexual activity as being associated with partner availability and better health, rather than age, normalises sexual activity and desire in later life.

CONFLICT OF INTEREST

The Rotterdam Study is supported by Erasmus Medical Centre and Erasmus University Rotterdam, the Netherlands Organization for Scientific Research (NWO), the Netherlands Organization for Health Research and Development (ZonMw), the Netherlands Genomics Initiative, the Ministry of Education, Culture and Science, the Ministry of Health, Welfare and Sports and the European Commission (DG XII). RFP is affiliated with Erasmus Medical Centre and Monash University. RFP is supported by a Heart Foundation Postdoctoral Fellowship (101927). RFP declares no further conflicts of interest. The writing of the manuscript and the decision to submit the manuscript for publication were solely at the discretion of RFP.