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.

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”.

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.

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.

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.

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.”

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.”

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.

Yet we have a responsibility.