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Aging Dis. 2012 October; 3(5): 373–384.
Published online 2012 August 25.
PMCID: PMC3501393

An Update on Female Sexual Function and Dysfunction in Old Age and Its Relevance to Old Age Psychiatry

Abstract

Numerous studies have now demonstrated that many older women retain an interest in their sexual lives. Yet, how many old age psychiatrists commonly check with older women about whether the depression they are treating, or the SSRIs (Selective Serotonin Re-uptake Inhibitors) they have prescribed, have adversely affected their patient’s sexual lives? We consider the latest evidence regarding cultural, social and medical influences on older women’s sexual lives and some specific issues which affect lesbian and transsexual people. We examine how mental illness and psychotropic medication in particular can adversely affect older women’s sexual functioning and at how difficult it often proves to be for women to seek help. We also focus on why doctors and in particular psychiatrists may not take a sexual history, look for sexual side effects or refer for appropriate treatment, especially when interviewing older women patients. Most published information about psychiatric training and sexual issues focuses on the younger male patient. We therefore aimed to provide a broad-ranging review of the literature regarding female sexual functioning in old age, the difficulties that can arise and the role that old age psychiatrists have an opportunity to fulfil, in this often neglected aspect of their patients’ treatment. From our review it was clear that, in the light of the increasing cultural acceptability of discussions regarding sexuality and older women, the training of student doctors and trainee psychiatrists needs to reflect this change so that old age psychiatrists can enhance the quality of their patient care.

Keywords: Female, old age, sexuality, chronic disease, help-seeking, psychiatry

“Sexuality in our later years is now positioned as a key element of successful aging.” Hinchliff et al [1]. Increasingly organizations such as the AARP (American Association of Retired Persons) are publicizing the cultural acceptability of ongoing physical closeness and contributing to gathering data reflective of this trend [2]. For example, on their website articles such as “Are You Savvy About Sex After 50? Take our quiz and then compare scores with your partner to see who comes out on top” are easy to find.

Numerous studies have now demonstrated that many older women retain an interest in their sexual lives. They are likely to feel better physically and mentally for doing so Brody and Costa [3].

Yet, how many old age psychiatrists commonly check with older women about whether the depression they are treating or the SSRIs (Selective Serotonin Re-uptake Inhibitors) they have prescribed have adversely affected their patient’s sexual lives? Most published information about psychiatric training and sexual issues focuses on the younger male patient as, in England, have the practical examinations of psychiatric competence with regard to sexual side effects of medication.

We aim to examine the latest data on female sexual functioning in old age, the difficulties that can arise and the role that old age psychiatrists have an opportunity to fulfil in this often neglected aspect of their patients’ care.

We will examine the latest evidence regarding cultural, medical and social influences on older women’s sexual lives including some which specifically affect lesbian and transsexual people. We will look at how mental illness and psychotropic medication in particular can adversely affect older women’s sexual functioning and at how difficult it often proves to be for women to seek help. We question why doctors and in particular psychiatrists may not take a sexual history, look for side effects or refer for appropriate treatment, especially when interviewing older women patients.

Method

We made this a selective review, due to the breadth of aspects covered. Multiple searches were conducted, mainly via Athens Login to the National Library for health in the UK. The following databases were accessed – BNI, CINAHIL, EMBASE, MEDLINE, PUBMED, PSYCHINFO. Search terms included female, women, old age, elderly and geriatric, sex, sexuality and sexual, lesbian and transsexual, psychiatry and nursing home. Relevant additional studies and websites known to the authors were included. Most research cited has been published since the year 2000 and much of it in the last two years. Some smaller studies have been included in areas where there is a dearth of larger studies to draw upon.

Are older women bothered about sex?

Nicolosi et al [4] as part of the Global Study of Sexual Attitudes and Behaviors (GSSAB), aimed to study “the sexual activity and the prevalence of sexual dysfunctions and related help seeking behaviour, among people in Europe aged 40–80 years.” This was a large scale study – both men and women were interviewed by telephone in 2001 and 2002. They came from Sweden, the United Kingdom, Belgium, Germany, Austria, France, Spain and Italy. Altogether 5023 women took part. Overall 21% of the women aged 70–80 had had sexual intercourse within the preceding 12 months and 25% of those sexually active women aged 70–80 had sexual intercourse more than once a week. Women aged 40–80 were asked, as part of the same study, whether satisfactory sex was essential to the maintenance of a relationship. 77% agreed that it was. Only 18% agreed that “Older people no longer want sex.”

There have been two recent large-scale studies in the United States which investigated the prevalence of sexual activity in the over-70s. According to the American Association of Retired Persons survey in 2009[5](www.aarp.org/home-family/sex-intimacy), the percentage of women over seventy having vaginal intercourse even once within the previous six months was 13.3%. Whereas the National Survey of Sexual Health and Behaviour, also conducted in 2009 and published by Hernbenick et al [6] 21.6% of women over seventy reported having vaginal intercourse within the previous year. These studies also indicated that masturbation was undertaken by 33–40% of women over seventy, showing ongoing sexual interest in this age-group.

In Sweden Beckman et al [7] found that Swedes over seventy appeared to be more sexually active and more sexually satisfied than they had been 30 years previously and that 56% of married women over seventy remained sexually active.

It is also worth pointing out that what counts as sexual activity can change, as women get older. Older people often redefine their sexuality. Hinchliff [1] noted “other activities engaged in as a couple may be viewed as sexual. Penetrative sex may be less of a focus for men and women”.

Having a positive attitude to sex appears to be an important factor when it comes to older people engaging in sexual activity DeLamater (2012) [8]. This point is emphasised by some studies looking into physical difficulties of various kinds, which have shown that having a physical disability which affects a woman’s’ sexual life does not necessarily have as much impact as how the woman feels about that physical disability. Lowenstein et al [9] who studied 380 women with Pelvic Organ Prolapse (POP) and concluded that “Sexual function is related to a woman’s self-perceived body image and degree of bother from POP regardless of vaginal topography. Sexual function may be more related to a woman’s perception of her body image than to actual topographical changes from POP.” Similarly Hinchliff et al, 2011[1] noted the discrepancy in some studies between the levels of women with clinically significant sexual dysfunction and the lower proportions of women within the same studies, who identified themselves as having a sexual problem.

The impact of aging on female sexuality

The foremost change in discussing the medical effects of aging in women with regards to sexuality is perhaps that of the menopause as DeLamater (2012) [8] indicates. This period of transition as Avis et al [10] discuss, rather than being a singular event, lasts on average 3.8 years and is preceded by the climacteric or peri-menopause which begins at the mean age of 47.5 years. It is during this climacteric period, when there is a gradual decline in the functioning of the ovaries, that symptoms begin to appear, consisting mainly of vaginal dryness and vaginal atrophy as Howard et al [11] discovered in their research of women aged 40 to 79. However, in their study of middle aged and older women in Australia, vaginal dryness was reported as completely absent in 35.8% of women and always present in only 11.5%. Furthermore, only 14.6% of women experience dyspareunia 50% or more of the time. Interestingly, they also found that the overall incidence of both dyspareunia and of dryness did not vary significantly in their age group of 40 to 79. However Leiblum et al [12] in their international study of 6,725 women from 11 countries including the UK, Germany, Japan, Canada, Spain, and Brazil found that the incidence of vaginal dryness varied significantly between different countries. In Italy vaginal dryness was reported by 5.8% of women, by contrast in Brazil 19.7% of women complained of the same problem. A similar picture emerged with reports of dyspareunia, which was experienced by 3.6% of women in Australia but 18.6% of women in Brazil; this contrast also casts some doubt over the value of extrapolating the results of Howard et al’s [10] study internationally. In addition, this detailed research found that there was significantly more vaginal dryness in the UK, Australia, Canada, Italy, Spain, Argentina, and Thailand in the 50–65 year old age group compared with the 18–43 year age group. Lastly, the researchers highlighted an important contrast in health beliefs in these two age groups; internationally, the majority of women under 50 attributed vaginal dryness to inadequate sexual arousal whereas the over 50 age group blamed this on their age or the menopause.

Crucially, this also illustrates the importance of how the individual woman perceives biological aging and may explain, to a certain extent, the varied views of attitudes towards sex post-menopausally as discussed by DeLamater (2012) [8]. Also there is little evidence that sexual desire declines directly as a result of the menopause as Hinchliff et al [1] discovered in their qualitative study of the sexual experiences of women over the age 50. It is also worth noting that there is little consistent evidence to show that the menopause causes depression as Eden et al [13] discuss in their review article; furthermore Avis et al’s [10] study of 2565 women aged 45–55 years in Massachusetts highlighted that previous depression is the most likely factor to predict depression at menopause, supported also by Guthrie et al’s [14] study of 438 Melbourne women. Clearly a complex biopsychosocial model is necessary to explain how the menopause effects female sexual functioning.

Although obviously not universal like the menopause, diabetes mellitus type II in the older woman is increasingly common internationally and the incidence increases with age as Whitehouse [15] indicates. In her literature review she highlighted two main consequences of diabetes; firstly, the direct effect of the disease on the physiology of the body and secondly, the psychological effects of diabetes. Firstly, hyperglycaemia which can commonly occur in poorly controlled diabetes and indeed before it is diagnosed is thought to reduce the hydration of the mucus membranes which include vaginal tissues therefore resulting in vaginal dryness and associated dyspareunia. In addition the increased incidence of urinary tract infections in women with diabetes can cause further vaginal discomfort. Additionally, diabetes causes significant pathological changes to vascular structures leading to potential damage to the blood supply to the vagina. This can result in reduced lubrication and diminished circulation to the clitoris, inhibiting engorgement during sexual arousal.

Secondly, the psychological effects of diabetes such as increased perceived tiredness, embarrassment about the disease as well as reported loss of desire all serve to indirectly reduce sexual function. There is a disagreement in the literature about whether type I or type II diabetes effects sexual functioning the most, with no conclusive answer. This lack of clarity could be accounted for by the lack of research. Enzlin et al [16] are scathing both about the scarcity and quality of research about diabetes and its effect on the diabetic women, whilst they corroborate Whitehouse [15] citing the combination of decreased or slow vaginal lubrication with reduced sexual arousal. However they suggest that problems with achieving orgasm are not more common in diabetic women.

Urinary incontinence and pelvic organ prolapse are also more common in the older woman. Unsurprisingly urinary incontinence results in significant psychological distress in many women, with the fear of urine leakage during intercourse uppermost in their minds, accompanied with increased feelings of guilt and disgust about sex as Melin et al [17] explored. They also found that the fear of incontinence led to women avoiding sexual contact. Interestingly in Tannebaum et al’s [18] study 2361 women with a mean age of 71 in Canada found that the women with urinary incontinence weren’t less likely to be sexually active, however the severe incontinence did correlate with less intercourse. Here, overall, they found age (younger) and marital (married) status to be better predictors of regular sexual activity. Closely related to urinary incontinence in effect is pelvic organ prolapse on women’s perception of their sexuality; a subject which Sublett [19] highlights is often unvisited by health care professionals and yet despite the scarcity of research on this subject, there may be a considerable impact on sexual function.

A common risk factor for diabetes mellitus type II, urinary incontinence and pelvic organ prolapse is obesity, a commonly known growing epidemic. Beyond the direct pathological links between these conditions and obesity it is important to consider the relationship between obesity and sexual function directly, on which there is little research as Zabelina et al [20] discuss. In their study of 9991 overweight and obese men and women they used the Impact of Weight on Quality of Life-Lite (IWQOL-Lite), a measure of weight-related quality of life tool, to explore sexual function. Interestingly the results showed that at all age groups, the overweight and obese women had less self-esteem, encountered more public distress at their perceived image and had a less active sex life than the men. They found that the frequency of sexual activity in the women took a sharp dive after the age of 25 and then levelled out, in contrast to the more gradual decline for the men. However, self-esteem increased every decade in women peaking aged 70 along with a consistent decline in public distress as they got older. This research did not compare obese or overweight individuals with those of a more healthy weight but the aforementioned study by Melin et al [17] usefully contrasts obese and non-obese women, finding the former group experiencing less sexual excitement, lower sexual activity and less satisfaction with their sexual lives. Yet dyspareunia and ability to achieve orgasm were not significantly different when obese women were compared with non-obese women. Obesity therefore clearly impacts on sexual function in women of all ages. There has, thus far, been very little research into the impact of obesity on the sexual functioning specifically of older women.

Although certain chronic illnesses have been discussed, the older woman may encounter a variety of debilitating conditions. Encouragingly however, Howard et al’s [11] Australian study which compared women with breast cancer, osteoarthritis and hypertension to healthy women of the same age, found little difference in their sexual function and satisfaction. Despite these findings the authors suggest that advances in medical care for the older women, would very probably lead to increases in sexual functioning in the future. Their findings were supported by Lindau et al’s [21] study of 6037 US American women where they found that men tended to have their sexual functioning impaired much more by chronic illness than their female counterparts at all ages. Good health was associated strongly with a good quality frequent sex in their study, however the exact causality and nature of this relationship is unknown.

Cultural and social influences on aging female sexuality

Hinchliff et al [1] highlighted some of the barriers to older people expressing their sexuality; “old bodies sit in stark contrast to contemporary images of sexuality, which portray a youthful physical appearance” and noting that because “sex has traditionally been linked to the natural order (reproduction), later-life sexuality has been viewed as a perversion”.

However attitudes are changing. Hinchliff et al [1] noted that “Sexuality in our later years is now positioned as a key element of successful aging.” The apparent health benefits of continuing sexual activities into old age are also becoming more noticed “Based upon a broad range of methods, samples, and measures, the research findings are remarkably consistent in demonstrating that one sexual activity (PVI {penile-vaginal intercourse} and the orgasmic response to it) is associated with, and in some cases, causes processes associated with better psychological and physical functioning.” Brody [22] concluded after his 2010 review of the literature on health and sexual activity. Psychiatrists will be particularly interested in the study, previously conducted by Brody and Costa [3] of a large representative sample of the Swedish population. They found that PVI frequency was a significant predictor of both men’s and women’s greater satisfaction with their mental health. Age did not confound these results.

Women tend to live longer than men. Thus one clear factor limiting the sexual lives of heterosexual older women is lack of a partner. This was highlighted in an unusual study in Germany where Beutel et al [23] examined sexual desire and sexual activity, but included all ages. Their overall sample included 201 women and 101 men over seventy and even some people in their nineties. In the over-seventies the major factor determining sexual activity levels was whether someone had a partner. DeLamater et al [8] also noted after his review that “relationship or marital status is perhaps the major influence on the frequency of heterosexual sexual activity in later life.” Additionally he highlighted the frequent presence of “cultural norms limiting sexual activity to persons in committed relationships”.

The sexual and general health of a woman’s partner also naturally affects their sexual lives. A male partner may also be experiencing the effects of aging, The effects of social, cultural, medical and pharmaceutical factors on the sexual functioning of men is however beyond the scope of this article.

As women get older they or their partners may not be able to continue without residential or nursing home care. Unfortunately this may make continuation of their sexual life very difficult due to staff attitudes and lack of privacy. “Their only privacy is between the sheets” by Bauer et al [24] in Australia demonstrated a lack of individual rooms and how difficult it was for residents to have privacy from other residents or from staff. Staff felt that their need for access was more important than residents’ privacy. “Staff and nursing home managers need to work toward developing a home environment that is supportive of residents’ sexuality rights, that permits sexuality expression and promotes a culture where all people concerned are comfortable with sexuality issues”, Roach [25] in 2004 concluded after looking qualitatively at staff attitudes in Western Australia.

Why do older women commonly not seek help for sexual difficulties?

Women often do not seek help for sexual problems Nicolosi et al [4] (GSSAB) found that 32% of their sample of 5023 women in Europe reported a sexual dysfunction. 11% had lubrication difficulties, 13% had an inability to reach orgasm and 18% had lack of sexual interest. This study found that of men and women who reported a sexual dysfunction, overall, 74% had not sought medical help. The authors did not report these results by gender because “the results were almost identical for men and women.” This study also asked respondents, who had not sought help for their sexual dysfunction why they had not done so. Their results highlighted four main reasons. About 76% of respondents said that they did not feel that they had a problem, 71% felt that it was not a medical issue, 39% felt embarrassed and 26% had concerns about affordability or access to medical care. Interestingly though, 59% of women agreed with the statement “I am in favour of the use of medical treatments to help older people enjoy sexual activity”.

Hinchliff et al, 2011[1] extensively reviewed the help-seeking behaviour of people over 50, with respect to their sexual functioning. Qualitative studies highlighted common beliefs that sexual difficulties were a normal part of old age and that the sexual difficulties were not causing much distress; people were “comfortable the way they were”. Difficulties were left to see whether they would resolve by themselves and were often not considered to be serious. It was common to feel that sexual functioning was recreational and as so, not so much a medical issue to discuss with a doctor. Some patients felt that the doctor might be uncomfortable with the subject of sex themselves and some older people even feared that a younger doctor may appear to disapprove of sexual activity in an older person.

Many older women suffer with chronic diseases which may impact upon their sexual functioning. Kedde et al [26] in the Netherlands sought to “investigate help-seeking behavior concerning sexual problems among people with a disease or an impairment” and to “determine factors and reasons that deter people from seeking professional sexological help”. Shame shyness and anxiety prohibited people and many were unsure which health professional to approach and doubtful that they would receive useful help. Unfortunately, when Kedde et al [26] enquired, it turned out that two thirds of those who had sought help judged the consultation they received negatively so people’s doubts appeared to be well-founded.

There is some research available regarding attitudes of doctors which illustrates that doctors themselves often subliminally or overtly discourage their patients from consulting them about sexual functioning.

Hinchliff et al [1] found that doctors were more likely to broach the subject of sexual functioning with younger patients than older patients in their review. They also found that cultural factors can influence attitudes of both doctors and patients, creating barriers to open communication, noting that there are noticeably behaviours in different countries.

It was established in 2001 that Psychiatrists, even Old Age Psychiatrists, are not immune from this as Bouman et al [27] illustrated in their study entitled “Are Psychiatrists Guilty of Ageism when it comes to taking a Sexual History?” They aimed to examine the attitudes and perceived clinical practice of psychiatrists with regard to taking a sexual history and management of sexual dysfunction in their patients by comparing responses of old age and general psychiatrists. They sent their questionnaire to 144 consultants in old age psychiatry and general adult psychiatry. The questionnaire contained one out of two possible two case vignettes. One described an 83 year old man with no previous psychiatric history and without any cognitive impairment, complaining of low mood for two months and the other described a 40 year old man with the same complaint. Questions then covered whether the consultant would take the various elements of a sexual history and if not, why not. They were then asked what their management would be if a sexual difficulty was identified. Their results showed, from 61% replies, that both groups of consultants were more likely to ask the younger man about sexual function and to refer the younger man for appropriate treatment. These authors postulated that factors which may have influenced the lack of history taking were that patients don’t tend to raise the subject themselves, Psychiatrists may “have difficulties disconnecting from their own personal belief system regarding aged sexuality” or they may just “lack awareness of physiological, pharmacological and psychosocial bases of sexual problems as well as of aged sexuality”. Similarly, with respect to treatment referral, their results showed that a Psychiatrist would typically refer a middle-aged patient with sexual dysfunction for sexual therapy but that an elderly man with the same problems would be referred to a community psychiatric nurse, who is not trained in sexual therapy. The authors concluded that taking a sexual history is often omitted in the psychiatric assessment of elderly men and that elderly men with sexual dysfunction do not receive appropriate referral and treatment. Bouman et al [27] reached the conclusion that “Human sexuality and particularly aged sexuality is an area that requires more attention in psychiatric training.” This study also begs the question; what would the respondents have answered, had the patient been female?

Rele and Wylie in 2007 [28] looked at the “Management of psychosexual and relationship problems in general mental health services by psychiatry trainees”. They sent a completely anonymous questionnaire to all psychiatry trainees in one region of the United Kingdom, regarding their perception of their competency in dealing with sexual dysfunction and relationship problems; the need to discuss potential sexual side-effects before and after starting psychotropic medication and the importance of a readily available psychosexual disorder clinic. The questionnaire also tried to establish the extent of their training on psychosexual issues and sexual medicine. 81% of trainees reported feeling inadequacy whilst dealing with psychosexual disorders during their training in psychiatry. Only 30% reported asking patients about potential sexual side-effects when on psychotropic medication. The authors concluded that training for undergraduates needed to focus on sexual health more fully and that trainees should be supervised and assessed so that they could demonstrate competence in this area of the curriculum.

Schindel et al [29] recently completed a larger scale study of US and Canadian Medical students. They received over 2000 self-selected replies to a wide-ranging survey which examined not only their attitudes towards discussing sexuality with their patients but also the students own sexual preferences and levels of sexual activity. They found that “the most powerful association of lack of comfort in dealing with patients’ sexuality was a perception of inadequate human sexuality training in medical school.” This was the case “irrespective of their personal sexual choices and experiences” These authors therefore highlighted “the importance of ensuring a quality human sexuality curriculum at medical schools throughout the United States and Canada.”

Issues specifically affecting older lesbian women

Although there is limited research available in this area, studies indicate that Lesbian women have specific concerns as they enter old age.

In their small-scale qualitative study of lesbians in New York, Howell and Beth [30] found that “Middle-aged lesbians expressed concern regarding who would care for them when they were old. What would they do when they could no longer use coping skills that they learned as young people facing homophobia? Some expressed hope that homosexual communities that supported them through their coming out processes would also meet this need. However, they were concerned that lesbian-friendly services were already difficult to find, even in New York City where many gay and lesbian service organizations exist.”

Similarly, Smith et al [31], who examined the views of Gay, Lesbian, Bisexual and Transsexual (GLBT) people in California noted that “Not a single participant thought that nursing homes were “very” GLBT-friendly and over half (52.6%) thought nursing homes were not GLBT-friendly. Almost as many (47.4%) thought that assisted living services were not GLBT-friendly. Equal percentages (36.8%) thought that senior centers and accessible transportation were not GLBT-friendly. About a quarter thought that in-home care personnel would not be GLBT-friendly.”

Neville et al [32], did a larger-scale survey, undertaken in New Zealand, entitled ‘Lavender retirement’: a questionnaire survey of lesbian, gay and bisexual people’s accommodation plans for old age” Of women (n=1001), 476 (47.6%) chose living with family/partner, 395 (39.5%) chose living in their own house, flat or apartment, 78 (7.8%) chose ‘other’ and only52 (5.2%) chose a general retirement facility.” They also found that, when women were asked what they would prefer if they were unable to live on their own,”1007 women respondents to this question, 593(58.9%) preferred an LGB-friendly retirement facility, 201 (20.0%) preferred to be cared for in her own home by public services, 122 (12.1%) preferred a general retirement facility, and 91 (9.0%) preferred some other accommodation option.” They advocated “ensuring nursing curricula covers topics such as sexuality, gender, discrimination, as well as relationships, friendships and lifestyle patterns of Lesbian, Gay and Bisexual people.”

Old age in the transsexual community

People have usually been part of the transsexual community for many years before entering old age but some people request gender reassignment when older as described by Docter [33] and previously by Lothstein [34]. Psychiatrists in old age therefore need to be aware that a strong desire to change gender can present in old age and know the appropriate referral procedure in their area.

For people within the transsexual community, aging can be a daunting prospect. Smith et al [31] in California collected some qualitative data from the LGBT community, which illustrates some perceived unmet needs. Their respondents’ suggestions included; “Have more gay friendly people that provide services,” “Begin to educate the organizations that cater to senior citizens about the need to be accepting of GLBT persons,” “More training for people involved in social services, nonbiased.” These comments appear to indicate a worry that as an elderly LGBT person, one might find oneself vulnerable to prejudice from professionals. Several people also expressed a preference for specialised services; “Open GLBT specific centers geared for senior GLBT persons to congregate” “More community activities for older gays/homosexual people and their partners” “Start an LGBTQ [lesbian, gay, bisexual, transgender, or queer] housing project, like they have in other cities.”

Jonson et al [35] in their 2012 Swedish study deftly illustrated how sexuality can adapt during aging for the LGBT community. “Turning vinegar into wine: Humorous self-presentations among older” LGBTQ, looked at self advertising in two Internet dating forums. Self depreciating humour about “old age, being overweight, impotence and other age-related changes were in fact part of a repertoire that displayed marketable characteristics such as humor, self-distance and honesty among advertisers.”

Direct effects of mental illness on female sexual functioning

Depression and anxiety are more common in older women and they are directly associated with increased anorgasmia and lack of pleasure according to Moreira et al [36]. Ching et al [37] in their unusual study of 73 unmedicated patients with depression alongside 116 healthy volunteers revealed that depressed women in all age groups had poorer sexual functioning than the control group. They also found that increased age was associated with poorer sexual functioning in the depressed group, whereas in the control group, sexual satisfaction continued to increase to the age 40, before starting to decline. Fabre et al [38] studied 1184 women, using the Hamiliton Depression Rating Scale and the Derogatis Inventory of Sexual Function tool. Here they found that a higher the depression score correlated with a lower the level of sexual functioning. However, this relationship between depression and sexual dysfunction is highly complex. Indeed there is evidence that penile-vaginal intercourse, crucially including ejaculation, leads to stimulation of hormones in women that can be psycho-protective, such as seminal prostaglandins, as Brody [39] discusses. The length of exposure to seminal fluid is also key, with women who void urine shortly after sex having a higher incidence with depression than those that don’t. This potentially leads to vicious circle in depressed women, whereby reduced libido from their mental illness engenders less sexual activity, which in turn reduces exposure to seminal fluid via penile-vaginal intercourse. This research does not directly discuss older women; however their increased incidence of depression together with the tendency for older women to engage in less frequent penile-vaginal intercourse makes these findings worthy of note.

There is again a great paucity of contemporary research on the effect on female sexual functioning of other mental illness across any age groups, let alone in older women. However, over 25 years ago, some interesting research was conducted by Raboch [40] on Czechoslovakian women which found there to be no difference in orgasmic response in bipolar patients, compared with a control group. However, he found those women with schizophrenia and “neurotic” disorders had much lower rates of coital orgasm than the controls with no mental illness. There is clearly an on-going need for research into the relationship between mental illness, especially those other than depression and sexual dysfunction in the older woman.

The dilemmas faced by dementia sufferers and their carers

Dementia is a pervasive disease of increasing prevalence, especially in Western societies, as people’s life expectancy has increased. Although quality of life maintaining treatments are increasingly available there is a steady progression towards widespread loss of mental faculties. This is often devastating for sufferers and partners, who are often redesignated as “carers”. When verbal communication is impaired, sometimes non-verbal communication and physical closeness can provide an intermittent window of comfort. However as the sufferer’s capacity to consent declines, couples can find themselves in a minefield, surrounded by well-meaning professionals. The Alzheimer’s Society: Sex and Dementia leaflet [41] (www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=129) outlines common changes that can occur in the context of dementia. These are a greater or lesser interest in sex, an increase or decrease in sexual performance, changes in sexual ‘manners’ − for example, appearing less sensitive to the other’s person needs or appearing sexually aggressive and changes in levels of inhibitions. This publication also provides some practical guidance for couples negotiating through these sometimes ethically challenging areas. The English National Institute for Clinical Excellence (NICE) recommends “At the time of diagnosis and when indicated subsequently, the impact of dementia on relationships, including sexual relationships, should be assessed in a sensitive manner”

There is even hope after dementia leads to care outside one’s own home. “Intimacy, Sexuality and Sexual Behaviour in Dementia: How to Develop Practice Guidelines and Policy for Long Term Care Facilities” [42] has been developed in Canada. This pragmatic approach aims to challenge the “pervasive” belief in society that “sex is for the cognitively intact”.

The effects of prescription medications on sexuality in the elderly

As the population ages the need for multiple drug therapies grows. Whilst many women in older age wish to continue their sexual relationships, the medicines they are prescribed can make this difficult and sometimes impossible. Additionally the medicines prescribed for their sexual partner can impair their sexual performance and as a result damage their relationship.

The potential for newly prescribed drugs to cause sexual impairment is easily overlooked at the counselling phase. Many prescribers may be unaware of their patients’ difficulties as a consequence of reluctance by the patient to talk about them. Direct questioning from the prescriber is usually required to open this dialogue. It is important that they are aware which medicines have the potential to impair sexuality in order to ask appropriate questions of those patients recently started on such drugs.

In order to predict the potential for a medicine to impair sexual function an appreciation of the normal mechanisms involved in sexual function is required. The central nervous system (CNS), parasympathetic system and the sympathetic system are all involved in normal sexual function.

  • Sexual interest or libido–mediated primarily by CNS
  • Arousal – mediated by CNS and parasympathetic system
  • Plateau
  • Orgasm/ejaculation – mediated by CNS and sympathetic system
  • Resolution

Many neurotransmitters, neuropeptides and hormones are involved in normal sexual reactions.

Psychotropic medication which may affect sexual functioning of women and men:

Antidepressants

Mixed anxiety & depression is a common mental disorder. For example, approximately 8–12% of the British population experience depression in any year according to the The Office for National Statistics Psychiatric Morbidity report [43]. Of these, half only experience symptoms for 18 months. However the poor, the long-term sick and the unemployed, three states often attributable to the elderly, are likely to be affected for a longer duration than the general population.

Sexual dysfunction is a known cause of depression but the relationship is complex. Unfortunately it is also a symptom of depression and can be an adverse effect of treatment with antidepressant medicines Seidman [44]. These confounding issues imply that there is a requirement to establish an understanding of the patients baseline sexual functioning before they were depressed and before they subsequently commence treatment with antidepressants.

Sexual dysfunction in men and women has been reported with nearly all antidepressant medication with reported incidence varying from 40% according to the Better Or Worse: A Longitudinal Study Of The Mental Health Of Adults In Great Britain report [45] to 59.1% according to Rothschild [46].

Delayed orgasm can be attributed to the anticholinergic effects of tricyclic antidepressants while decreased libido is a result of their dopamine antagonist properties. Females not requiring antidepressants may still experience the results of tricyclic antidepressant sexual adverse effects such as erectile dysfunction and impaired ejaculation in their male partner. Beaumont [47] highlights that elderly patients are especially vulnerable to many of the side-effects of tricyclic antidepressants.

The selective serotonin reuptake inhibitors (SSRIs) are increasingly common drugs prescribed for depression, yet they also carry a risk of worsening sexual function. Montejo et al [48] observed that delayed orgasm is seen with the SSRIs along with decreased libido, anorgasmia, and decreased vaginal lubrication. Citalopram and paroxetine were shown to be relatively likely to have had an effect in the Montejo et al study [48]. The sexual adverse effects of SSRIs are thought to be caused by increasing synaptic concentrations of serotonin stimulating 5HT2 and 5HT3 receptors resulting in decreased levels of dopamine activity, according to Michael et al [49]. Specific resources should therefore be directed towards the education of prescribers to help identify those patients most at risk and monitor for treatment emergent sexual side effects. As with the tricyclic antidepressants, females whose male partners are taking an SSRI may still experience sexual adverse effects as a result of erectile dysfunction.

Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, was identified in one study by Montejo et al [48], which compared several antidepressants, as having a relatively high incidence of sexual dysfunction (67.3%). Effects may include decreased libido, delayed orgasm, anorgasmia, decreased vaginal lubrication and in men, erectile dysfunction.

Mirtazapine is a selective 5HT2 and 5HT3 antagonist, which may explain the relatively low frequency and intensity of sexual dysfunction (24.4%)[48] as compared to some SSRIs. As a consequence of its low frequency and intensity of sexual dysfunction, mirtazapine may be considered a viable choice as an alternative antidepressant for women experiencing sexual dysfunction.

It remains unclear what effects trazadone has on sexual function; Rattya et al [50] reported increased libido.

Duloxetine’s effect on sexual function was assessed in 4 randomised double blind placebo and paroxetine controlled trials in patients with major depression in a study by Delgarno et al [51]. It was found to have a higher rate of treatment-emergent sexual dysfunction (46.4%) than placebo (28.8%) but significantly lower rate than paroxetine (64.1%).

Like the tricyclic and SSRI antidepressants the non-reversible MAOIs may produce sexual dysfunction, which is suggested to be as a result of their serotonergic stimulating action. Physiological effects are similar to those of the tricyclic antidepressants. Rothschild [46] suggests the alternative of moclobemide, a reversible MAOI with a lower reported incidence of sexual dysfunction and which may even have a stimulating effect on sexual function.

Anti-epileptics

Epilepsy can affect reproductive function and sexuality. This is likely to be because many patients report low satisfaction with sexual relationships in the context of feeling stigmatized by having the condition according to Harden [52].

Changes in sex hormone levels in patients with epilepsy may be attributable to the condition, the antiepileptic drugs or to both. Findings in women with epilepsy include abnormal levels of prolactin, luteinizing hormone, estradiol, sex hormone binding globulin, and dehydroepiandrosterone. The hepatic enzyme-inducing anti-epileptic drugs; phenobarbital, phenytoin, carbamazepine, and oxcarbazepine increase hepatic synthesis of sex hormone binding globulin and the metabolism of sex hormones. Lambert [53] reports that lamotrigine, which does not induce hepatic enzymes, appears not to affect sexual function.

Anti-parkinsons drugs

The physical manifestations of Parkinson’s disease (PD) impair the ability to perform sexual activity successfully. In addition, the effects of PD also produce a range of symptoms that can impair sexuality. In both genders loss of libido is common while in men erectile dysfunction and delayed ejaculation is seen also. In women vaginal tightness and dissatisfaction in sexual intercourse has been noted. Sakakibara et al [54] discuss that treatment of PD using dopaminergic drugs improves sexual functioning to some extent however pathological hypersexuality may occur which they attribute to the dopamine dysregulation syndrome in this disorder.

Antipsychotics

Stimmel et al [55] highlight that sexual dysfunction can occur in patients with schizophrenia but that it is more likely still to affect individuals who are taking antipsychotics. Advanced age is one of the factors influencing the degree of sexual dysfunction. Also relevant are the class of antipsychotic, higher levels of depression and concomitant disease/drug therapy according to Stimmel et al [55].

The most common sexual side effect of antipsychotics is reduced libido affecting 30% to 60% of those taking older antipsychotics affected and up to 43% of those taking newer atypical antipsychotics in the Stimmel et al review [55]. This is apparently related to dopamine antagonism and the increased prolactin levels caused by dopamine blockade. Risperidone has been found to cause elevations in prolactin levels relatively frequently. Olanzapine and clozapine are respectively less likely to cause this and quetiepine less likely still [55]. The older conventional antipsychotic drugs such as chlorpromazine, haloperidol and fluphenazine are potent dopamine blockers. These may cause up to 60% of patients to experience sexual adverse effects [55].

Hanssens et al [56], in their trial comparing aripiprazole with standard care (olanzapine, quetiapine or risperidone), found that both groups experienced improvements in sexual function when compared with baseline assessments. However at 8 weeks the aripiprazole group reported significantly greater improvement compared with the standard care group. Although baseline mean serum prolactin levels were similar in the two treatment groups, at Week 26, mean decreases in serum prolactin were 34.2 mg/dL in the aripiprazole group, compared with 13.3 mg/dL in the standard care group. The study concluded that “aripiprazole has the potential to reduce sexual dysfunction, which in turn might improve patient compliance.”

Benzodiazepines

Benzodiazepines such as diazepam and temazepam are often used at relatively high doses for the treatment of anxiety and panic disorders. Together with the drowsiness you would expect they have been found to cause reduced libido and ejaculatory difficulty in the Hanssens et al trial [56].

Old Age Psychiatry and sexual functioning

So, what has sexual functioning got to do with psychiatry, anyway? The effects of mental illness on female sexuality and sexual functioning have already been addressed. Also we have examined the role of psychotropic medication on sexual functioning. Therefore surely, sexual functioning and any changes to it are the business of the psychiatrist. In addition, we have established that training in this area at the undergraduate and postgraduate level in Psychiatry appears to be insufficient which impairs communication with patients. Nnaji et al [57] looked specifically at sexual dysfunction in schizophrenia and found “As regards training in the management of sexual dysfunction in schizophrenia, 62 psychiatrists (81.6%) had not had any; 60 respondents (78.9%) agreed they would want training, with 19 (26.3%) agreeing strongly that this was required.” Although awareness of sexual dysfunction has been rising over recent years amongst psychiatrists, this awareness still tends to be focused on the needs of younger men, just as it was for Bouman [27].

Yet we have a responsibility.

Stevenson [58] in Canada in 2004 asserted “For an area of life and health that is so fundamental and pervasive, professional ignorance or inattention to possible sexual problems does not meet current standards of psychiatric practice.” and “it may be argued that it is indefensible not to take a good screening sexual history from each patient.”

Conclusions

The prospect of a good sexual life for older women appears to be improving. The internet is providing more resources for older women to seek and find information and sexual aids. Information can be found via the AARP [5] website and the Sexual Advice Association (www.sda.uk.net), which also provides a helpline in the United Kingdom. It additionally provides specific information about how to approach your General Practitioner about a sexual difficulty. As pointed out by Hinchliff et al [1] the internet also enables people who are not able to travel easily, to obtain items to assist their sexual functioning by post and anonymously. Finding partners can be facilitated by websites as highlighted by Jonson et al [35].

The authors were unable to find any specific research investigating the attitudes or practice of Psychiatrists regarding the sexual health of their older women patients despite the known effects of mental illness and psychotropic medication on female sexual functioning and the increasing awareness that many older women treasure their sexual lives. Psychiatrists have a unique opportunity to address this topic with their patients. Usually the psychiatrist has more time with their patient than, for example, their general practitioner. The psychiatrist is also routinely overcoming psychological barriers to ask “difficult” questions. If psychiatrists can address the myriad of psychotic symptoms and suicidal ideation with their older female patients, is it really so difficult to enquire about and appropriately address changes in sexual functioning? Training in both medical school and for psychiatric trainees appears to be fundamental to overcoming the identified barriers to this aspect of patient care.

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