Sex and the Older Woman
Find out about female sexual dysfunction among older women and the treatments that lead to active sexual lives.
Summary & Participants
Despite what many people think, older women can lead healthy and active sexual lives. But this doesn't mean it will always be easy. Our panel will discuss the challenges to an elder woman's sexual life, and how to face them.
Mark Pochapin, MD
Weill Medical College of Cornell University, New York
David Kaufman, MD
Columbia University, College of Physicians and Surgeons
Patricia Bloom, MD
Mount Sinai-New York University Medical Center
Dagmar O'Connor, PhD
MARK POCHAPIN, MD: Hi, thank you for joining us today. Today we're going to focus on people who are considered "the elderly." However, when we think about elderly people, we often think about people who are not very active. Today, not only are we going to talk about activity, but also we're going to talk about sexual activity.
Starting with us today are a few of my guest panelists. To my left is Dr. David Kaufman, who's an assistant professor of clinical urology at Columbia University. Welcome. Sitting next to David is Dr. Patricia Bloom. She's the chief of geriatric medicine at St. Luke's/Roosevelt Hospital here in New York City. Welcome, Patricia. Sitting next to her is Dr. Dagmar O'Connor, who's a psychologist, a sex therapist, and really the first woman sex therapist to be trained by Masters and Johnson in New York City. Thank you all for joining us today.
Let's start off with sex and the elderly woman. When we talk about "elderly woman," what are we talking about? David, what is considered to be elderly now?
DAVID KAUFMAN, MD: I think that really has changed dramatically over the last few decades. As the Baby Boomers are getting older, it's really hard to consider somebody over the age of 55, which might have been considered a senior in the past, as elderly, because they're just really exhibiting behavior patterns that they've been exhibiting for a long time. I think that probably for the purposes of this discussion, we should really be speaking about the eighth decade of life if my panelists agree with me there.
DAGMAR O'CONNOR, PhD: I often think that the woman feels old when she enters menopause. That's the first real sign of loss of reproductiveness and the purpose of life. That is the time when most of the trouble starts in terms of sexual functioning.
PATRICIA BLOOM, MD: So you would say anytime between 45 and 55.
DAGMAR O'CONNOR, PhD: I would think so.
PATRICIA BLOOM, MD: Although technically speaking, as a geriatrician, it's over the age of 65. But I will agree with David that our, I guess as all of us approach, we like to push it.
DAVID KAUFMAN, MD: I don't like the 45 part being considered elderly.
PATRICIA BLOOM, MD: But especially talking about sexual activity, I think what is interesting is that people don't even conceive of people over the age of 80 being sexually active. But I think you would agree, surveys show that actually the majority of people over the age of 65 are still sexually active. And even when you get into the 80 and above, still about a quarter to a third of elderly, even women and men, have sexual activity. And that's something that people generally don't think about or wouldn't believe is true.
MARK POCHAPIN, MD: Right. It's actually, certainly not a topic that you hear much about. It's not a focus in either medical schools or in the curriculum, and it's something that seems to be appropriate, given the fact that there are plenty of people who are sexually active who are considered elderly.
DAGMAR O'CONNOR, PhD: I treat quite a few couples who are in their eighties, and it's a surprise. They would never dare to tell their grandchildren or their children that they could sneak away and see a sex therapist.
MARK POCHAPIN, MD: Let's start with the physical changes. Obviously, as someone gets older, there are physical changes that occur in their body. David, what is occurring in a woman from a medical perspective that might make sexual activity different?
DAVID KAUFMAN, MD: I think what comes to mind first is, along with menopause and the changes that accompany menopause, there's a decrease in the ability of women to lubricate as they get older, and that certainly impacts on their ability to enjoy sex, and perhaps participate in sex because of their lack of enjoyment.
There are also medical conditions that occur, such as atrophic vaginitis, which occurs as women get older, where the tissue itself becomes less elastic and the vaginal opening becomes smaller, and that also interferes with a person's ability to participate in sex, and certainly enjoy sex. Now, all of these problems have medical solutions to them, and I'm sure Dr. Bloom takes care of these conditions on a regular basis.
MARK POCHAPIN, MD: Now, what do you do? Do you actually address these problems with the patient, or do they actually tell you about them?
PATRICIA BLOOM, MD: That's a very good question. In fact, a big part of what I do is training young physicians. And we really have to remind them to ask about sexual activity because, as I said, people have assumptions that, if you're over a certain age, you're not sexually active. And I think it's very helpful for elderly people, if the doctor does ask them. Because, as you said, they might be somewhat embarrassed or think that it's not a problem that's okay to bring up in the office. So, yeah, I think the physician should ask.
In addition, the actual changes in the vagina and the surrounding tissues are a critical part of what affects older women, but in addition to that are their medical conditions, which can influence either their interest or their ability. And there's a whole range of that, from women with heart disease, who might get chest pain when they're vigorously sexually active, to people with lung disease who might get breathless, or people with arthritis who have difficulty positioning themselves.
And then there's the whole affect of conditions, which influence women's self esteem, which might just be changes in the body. We live in such a society that thinks you have to be a svelte, lithe young thing to be sexually active. So there might just be embarrassment about shifts in body composition or having a stomach. Or, farther down the line would be things like having had a mastectomy or a colostomy bag or other conditions like that, where women would really have a loss of self-esteem and feel embarrassed, especially if it's with a new partner. Then the situation of having a new partner late in life is a whole new thing that Dagmar probably deals with.
DAGMAR O'CONNOR, PhD: It's a very difficult thing. I think even younger women have body image problems. And then it gets quadrupled when you get into old age. But the nice thing about old age, remember, that your partner also loses his eyesight. It's not as dramatic. But many of the women prefer to have sex in the dark. Many of their partners, men, are much more visually oriented than women and it becomes a problem. "Why do we always have to have it in the dark?"
PATRICIA BLOOM, MD: Do you find that you can convince women to somehow shed that embarrassment and feel somehow more accepting of their bodies?
DAGMAR O'CONNOR, PhD: Absolutely.
PATRICIA BLOOM, MD: How do you get them to do that?
DAGMAR O'CONNOR, PhD: I run sexual self esteem workshops for women of all ages, and men as well. Part of it is learning to love your body the way it looks right now. And I remember a woman who said to me "I didn't learn to love my body until I lost it."
MARK POCHAPIN, MD: That's very interesting. I think sort of in a crisis oriented society, you could see that happening. In all medical care, it seems to be related to when something's a problem, people address.
DAGMAR O'CONNOR, PhD: It's also important that some of these problems, vaginal problems, there are things you can do about them, and by the time they end up with me in the sex therapy, some of the thinning of the vagina and the painful intercourse can be taken care of by some friction, and what I call traffic. The tissue is the same as any tissue in our body. The more we rub it, if we don't do it too much, the more it stretches. So I work a lot with women to make them more comfortable by just practical means. And also getting them ointments or lubrications.
MARK POCHAPIN, MD: How do women come to a sexual therapist? In other words, do they come on their own? Is it a physician that refers them? Is it a urologist or geriatrician? Because as we said earlier, this is really a subject that doesn't get much attention.
DAGMAR O'CONNOR, PhD: A mixture. I get referrals from all of you, and I also get referrals from my book/video packet, which is a do-it-yourself video packet for sex therapy. Couples start using it, and then they get stuck somewhere and they call me. And the so-called transference has already taken place. They know me already.
Also by friends. You feel safe when you have a friend who says "I know this person, and they make me feel safe." So that's another way.
MARK POCHAPIN, MD: The self-esteem issue is interesting to me, because that's obviously an issue that's not age related. That begins way back, but seems to become more of an issue as someone gets older. Or maybe it just becomes more of a focus. But how do you address that? What do you do about someone who really doesn't have the self-esteem to move ahead?
DAGMAR O'CONNOR, PhD: It's very often asking them to confront the problem upfront. If you learned that you have to look like a model in order to be sexual, you have to start looking at what you've got. And I have the women stand nude in front of a mirror and look at their bodies and draw pictures, as an artist. I say: "I don't want any comparisons." You've got to come away from this event loving five things about your body. They may start with their feet or their fingernails, but they slowly have to grow to love it. You only do that if you look at it often.
MARK POCHAPIN, MD: Pat, as a geriatrician, you see someone, let's say, for a problem with chronic lung disease or a problem with chronic heart disease. You put it in the appropriate social setting. When does the issue of sex and sexual function come up? Is that something that you bring up with every patient you see? Or is it something that you wait to be addressed with you?
PATRICIA BLOOM, MD: I try, as part of the initial assessment, to ascertain whether people are sexually active. If they are, is it satisfying? Are they having problems with it? If they're not, do they wish they were? That sort of gives them permission to talk about it. They might not want to explore it very much on that visit, but at least it opens the door to communication. And then, hopefully, I on every visit will ask them if there's anything else they're concerned about. They may bring it up on subsequent visits, see if it's not something that's bothering them at the time of their initial visit.
But I think having an open door kind of dialogue is helpful. Similarly, I think with, talking about self-esteem, a lot of these issues have to do with communication. Getting into what does the person want. That is at the basis of all of these issues, whether it's with a partner, an old partner or a new partner. And, interestingly, for some elderly people, that's the biggest issue. They don't have a partner.
There are some interesting relationships that form as a result of that. Some women who've been heterosexual all their lives may form a very nice relationship with another woman. And some people who just don't have a partner at all might find that self-expression of sexuality is something that they enjoy exploring in their later years.
DAGMAR O'CONNOR, PhD: Making love to yourself, as I call it, is an important part of being sexual. It's not what we say is shameful that we do quickly, but when you make love you give yourself foreplay, and you take your time, and you give yourself love.
PATRICIA BLOOM, MD: The thing that it's important, I think, for everyone to remember, is that when we're talking about elderly people, people who are elderly now, whether you're talking about 65 or 75 or whatever, most of that category of people grew up, their whole lives, not talking about sex. I think that people's willingness to be open and talk about sex came later. There has been a sexual revolution.
DAVID KAUFMAN, MD: There has been a sexual revolution, certainly, lately, because of the pharmaceutical.
MARK POCHAPIN, MD: In older patients?
DAVID KAUFMAN, MD: Well, I think so. I think in everybody. But since the advent of some of the new pharmaceuticals that have come out, of course, Viagra (sildenafil citrate) by Pfizer, where there are now commercials on television with ex-presidential candidates talking about their sexual problems, it really has opened up the door and allowed for people to come and acknowledge that there may or may not be a problem in their lives. And I think they are speaking about it more.
When it hit the pharmacy shelves, my office was inundated with people who are suddenly facing the fact that they do have a problem. And now that they knew that there was something available that was fairly easy to take, a pill, they were really coming out of the woodwork looking for answers.
And since we're on the topic of women right now, there has been some amount of research, based in Boston, of using this drug Viagra (sildenafil citrate) in the treatment of female sexual dysfunction. When the news articles hit the stands about the results of that research, I had a tremendous number of women ask me questions about its possible role in their treatment.
MARK POCHAPIN, MD: There is a role, possibly, for women using Viagra (sildenafil citrate)?
DAVID KAUFMAN, MD: That's still under examination. I don't know how technical you want to get right now, but there's no question that drugs such as Viagra (sildenafil citrate) will increase clitoral blood flow. Which is really analogous to what Viagra (sildenafil citrate) does in men, that it improves the quality of the erection. And that's been proved with Doppler ultrasound, that clitoral blood flow does increase. Now, of course, female sexuality is probably more complicated that than, so just because they have increased clitoral blood flow doesn't mean that their sex drive and their ability to enjoy sex, and their ability to reach orgasm, for instance, is necessarily improved. But the drug does work, and it does do what it's supposed to do, which is increase blood flow.
MARK POCHAPIN, MD: The point being that there are now drugs being aimed at older people, for the sole purpose of engaging in sex, is really something that goes along with the fact that we have to start talking about that.
Well, I appreciate the three of you on our panel tonight. It's a very interesting topic. I certainly learned quite a bit, and I'm sure our audience has learned quite a bit as well. Older people have a life, and with that life, they should enjoy the same pleasures that they did when they were younger.
This is Dr. Mark Pochapin. Thank you for joining us tonight.
next: Menopause and Sex