Introduction
Methods
Sample and procedure
Characteristics | N/M | % |
---|---|---|
Age, years | M = 49.84, SD = 10.18 | |
Seniority, years | M = 20.37, SD = 10.20 | |
Country of origin | ||
Israel | 30 | 78.95 |
United States | 1 | 2.63 |
South America | 1 | 2.63 |
Europe | 3 | 7.89 |
Eastern Europe | 2 | 5.26 |
Russia | 1 | 2.63 |
Sex | ||
Male | 22 | 57.89 |
Female | 16 | 42.10 |
Medical specialty | ||
Family Medicine | 17 | 44.74 |
Urology | 6 | 15.79 |
Gynecology | 11 | 28.95 |
Rehabilitation | 1 | 2.63 |
Psychiatry | 3 | 7.89 |
Training in Sexology | ||
Yes | 15 | 39.47 |
No | 23 | 60.53 |
Data collection
1 | How do you define sexuality? |
2 | Tell me about sexual function in old age. |
3 | Do the reasons for engaging in intimate relations differ between young adults and older adults? |
4 | In your opinion, what reasons might elderly individuals have for refraining from engaging in intimate relations? |
5 | In your opinion, which factors might influence the levels of sexual function and sexual satisfaction in old age? |
6 | How do you think society/the media perceives sexuality among the elderly? |
7 | How does treatment of sexual function differ between younger adults and older adults? |
8 | Tell me about contacting/referring patients to different specialists in relation to sexual function difficulties among the elderly. |
9 | What are the advantages/disadvantages of contacting different specialists in relation to sexual dysfunction in old age? |
10 | In your opinion, how is it possible to create open lines of communication about sexual function between elderly patients and their physicians? |
Data analysis
Sources of trustworthiness
Results
What (is the role of sex in later life)?
“A person is never too old or too sick to be sexually active. Our job as physicians is to enable people to be sexually active until the day of their funeral.” (Matthew, Psychiatrist, Sexologist).
In addition, when discussing sexuality in later life, physicians have specific assumptions about what older men and women want. According to many physicians, older men define themselves by their ability to achieve an erection and intercourse. In contrast, older women have a greater need for intimacy and emotional closeness. Based on these assumptions, both female and male physicians defined a successful sexual engagement in older age as the ability to achieve an erection and the ability to engage in penetrative sex:“I think the frequency (of sex) decreases. It's hard to say, because people don't really report to me about the frequency, and I don't really know what happens in people's bedrooms … But I feel there is a serious decline with age, across the years … ” (Lily, Family Medicine).
This approach, which assumes older adults definitely desire sex that includes penetration, also assumes that older adults are heterosexual. A few physicians admitted to assuming older patients are heterosexual. While they carefully address the issue of sexual orientation with young adults (e.g. ask if they are in a relationship and not imply that they have a boyfriend/girlfriend), they automatically assume older adults are in a heterosexual relationship:“For men, what is important is their sexual function, full penetration … women are not as interested in intercourse because of the pain due to vaginal dryness; however, they seek touch and relationship, so I prescribe lubricant or vaginal creams” (Ruth, Family Medicine).
However, some physicians, mostly those with training in human sexuality, differed in this matter. According to them, sex in older age is not only about penetration, but encompasses intimacy, warmth and touch. They emphasized that older adults engage in sex not just for penetration, but also to strengthen their relationship, feel closer to their partner, feel loved, and feel young again. They emphasized the importance of normalizing and calming the patient. These responses might be the message older adults were looking for and can explain why some physicians emphasize that sexuality involves much more than penetration and encourage their older patients to be creative in their sexual expression:“You know, when we talk about sexual function of older people, I am still held captive by the idea that sexual function, that is more ah … heterosexual. I mean, I don’t recall asking older people about other types of relationships. It is like in older age, that goes without saying, but with younger adults, I will be much more careful and ask, “Are you in a relationship?” and not, “Do you have a girlfriend … ?” (Emma, Family physician).
According to this view, physicians cannot define sex, what enjoyable sex is, or what is the goal of sex. Physicians noted pleasure and orgasm can be obtained by many means beside penetration and when they asked their patients what they wanted, they were surprised to hear that older adults were sometimes satisfied with sex that did not include intercourse, but just hugging, kissing, caressing or giving/receiving oral sex:“Sex is not a race and does not equal penetration. It is possible that older people would want intimacy without intercourse. Everyone can have it their way … just hugging, cuddling, stroking each-other” (Joseph, Gynecologist and Sexologist).
“When you ask people what is sex, they will say sex is a penis penetrating a vagina. But clearly, that is only one type of sex. Even if a woman has a decrease in her libido, or a man has decreased erectile function, they can still have wonderful sex if we help them define what sex is, and what the meaning of having sex is. Mutual pleasure could be obtained in many ways” (Daniel, Rehabilitation Physician and Sexologist).
Why (do older adults experience sexual problems)?
Based on these working assumptions, when referring to older adults, physicians focused on the physical aspects of sexual function among older women (vaginal dryness, decreased libido due to hormonal changes) and men (erectile dysfunction and delayed ejaculation). When examining older patients, physicians tended to ignore psychological and emotional aspects, and first sought an organic source for the dysfunction.“With younger adults, I expect to see sexual dysfunctions that are more psychological, whereas with older adults I assume the sexual dysfunctions are more of a mechanical dysfunction, and not performance anxiety or other psychological disturbances … ” (Don, Urologist).
However, although sexologists have described a broader examination which included social, dyadic and psychological aspects, most physicians in the study assumed the source of the sexual dysfunction in older age was organic, and this assumption perhaps affected and biased the interventions offered. These assumptions effect the diagnosis process among young vs. older patients. For example, some physicians disclosed that while conducting regular procedures, they always notify the patient about possible effects on sexual function (if relevant); with older patients, they sometimes forget to do so, and it just slips their mind:“There are social changes … children leave the house, and you stay only with your partner. Sometimes intimacy grows stronger, but sometimes the opposite happens, and sex is like an explosive material … Also, often, when there is more free time, people go back and fight over things that happened or didn’t happen in the past” (David, Gynecologist and Sexologist).
“There are some ages, when I … for example when an 80-year-old man comes with a problem of hydrocele, water in his testicles, I sometimes 'sin' and do not ask about sexual function … and then they ask. It comes from them … ” (Rene, Urologist).
How (sexual concerns in later life are treated)?
With younger patients, physicians described taking more time to understand whether the source of the dysfunction is emotional rather than functional. They try to avoid medication and provide more guidance in psychological issues relating to the sexual dysfunction. Physicians said that they discuss the importance of receiving relationship counselling and developing open communication with one’s partner, more than they would with older adults:“With older adults, I start much faster towards injections, because I don't trust the efficacy of testosterone, Viagra, Cialis, etc. I refer young adults to a sexologist, but I never do that with older adults, because the basic assumption is that the dysfunction is mechanical” (Don, Urologist).
As a result of the different treatment offered to younger vs. older patients, some of the physicians reported differences regarding the involvement of the partner in the treatment. With older patients, to whom they tend to prescribe medication, they do not necessarily invite the partner. However, when they provide consultation or refer the patient to sex therapy (most likely the younger patient), they emphasize the importance of the partner’s participation in the process:“With younger adults, therapy is more psychological. Meaning, we will work more on couple therapy, sex therapy, emotional aspects of sexuality, how to focus during sex, and sexual techniques, we will work more on the emotional aspects … With older adults, we will focus on the organic and physical aspects, which we can treat with medication … ” (Michelle, Gynecologist and Sexologist).
This biomedical approach seemed to intersect with and build upon the assumption that older adults want penetrative sex, and that the etiology is attributed to dysfunction that occurs at older ages. Physicians perceive that they need to provide treatment that will enable penetrative sex. Penetration was perceived as the ultimate successful result of their intervention. Therefore, older men were offered PDE5 inhibitors to enable them to achieve an erection, and lubricants or estrogenic creams were offered to older women, so they will not experience pain during intercourse. Physicians described how they plan to assist older patients to achieve an erection, starting with screening their hormonal levels, prescribing oral pharmacotherapy (PDE5) and offering intracavernosal self-injection therapy, vacuum pump devices and even penile implants.“With young adults, I try to give more guidance around the relationship, and do not rush to prescribe medication. I talk with them about the importance of counseling and sharing the difficulties with their partner. I will want their partner to come and will explain to both of them that their difficulty is not physical, but is based on their experiences, low self-esteem or anxiety.” (Emma, Family Medicine).
The physicians who had these perceptions on sexuality emphasized the importance of normalizing and calming the patient as part of their intervention. According to them, when physicians rush to offer medication, they validate that something is wrong with their patient’s sex life that needs to be fixed. However, even some sexologists were only able to adopt broader definitions of sex after trying conventional treatments (such as Viagra or lubricants) that failed. Only then, they offered their older patients a different perspective on sex:“I treat people, a woman, whenever and however she is. When I take medical history, I am interested in how she defines the problem, and I do the same for a young 25-year-old, a 42-year-old woman, or a 72-year-old lady. It is all the same to me” (Neomi, Gynecologist and Sexologist).
“I had a patient (60) who had painful intercourse and I wasn't sure I could help her anymore, so the next stage was helping her, and her partner adapt to the idea of sex that does not include intercourse and not to view penetration as a sacred goal … ” (Mellie, Gynecologist).