We talk to children about sex using the ‘birds and the bees’ story – where the birds produce eggs and the bees pollinate plants – as examples of sexual reproduction. We also need a lesson about sex in older age as the rules of the game change.

Rather than needing less sex, we need more intimacy and more sex in later life, as this informs the body that it is useful and happy, keeping us alive longer. There are other ways of achieving intimacy and happiness, but for a tried and tested method, you cannot beat sex.

We know that having sex prolongs life. If sex were a pill, it would be the most successful pill for increasing life than anything else on the market. And yet, knowing the effectiveness of sex, we shy away, bringing up these issues in a clinical visit. The truth is sex becomes more complicated as we age.

Things that happen around us affect how we feel and how we function and how interested we are in sex. For example, many things diminish our desire for sex: most (if not all) medications, drug and alcohol use, stress and other problems we are facing, health issues, depression, dementia and family trauma all reduce our desire and enjoyment of sex.

For most women, because they live longer and tend to marry men older than themselves, the single most important fact is that their spouse has since died and they have no partner. Other factors include being in hospital or a nursing home that restrict the availability and opportunity for intimacy.

Even if none of these issues exist, there are changes to the body that affect how we perform and enjoy sex. There is an intimacy dance that we do with our partner and most of the time the dance becomes uncomfortable and we stop participating. The sadness of this is that we also lose having intimacy with that person.

For women, sex is just more complicated because they have a complicated body and a complex psychology to go with sex. They also have menopause to contend with. Although the majority of middle-aged women report that sex is moderately or extremely important to them, menopause affects this. But sometimes the effect is exaggerated.

A study among Australian women, who were observed for eight years as they pass­ed through natural menopause, reported that there was a decline in sexual interest and responsiveness, but menopause did not affect the frequency of sexual activity.

On the other hand, those who had surgical menopause – who had their ovaries removed – had a much more drastic negative effect on sexual desire and sex. But this is not surprising since there is both an unnatural sudden decrease of hormones as well as surgery to contend with.

There are strong economic motivations to label female sexual behaviour as deficient in order to promote medication. There is even a name for it: hypoactive sexual desire disorder (HSDD). The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) labels HSDD with female sexual arousal disorder (FSAD) under the category of female sexual interest/arousal disorders (FSIAD). It is a psychiatric disease. But we will see that this not true.

Most differences can be accounted for by cultural, religious, ethnic and individual variation, and for the rest there are other factors that result in a decline of sexual desire other than a psychiatric or chemical imbalance.

In 2015 an international team comprising Andrea Burri, Peter Hilpert and Timothy Spector found that desire and arousal are the main agents of sexual satisfaction – again highlighting the fact that sexual behaviour involves a partner in most cases. It’s a social interaction. There is so much variance in sex and sexual appeal that we do not even know how to describe normal.

Desires at 16 and at 65 are not the same, and especially sexual desires. Both might be labelled abnormal, but they are normal for us at that age.  

Internally we are not helped as the body also changes and makes things different (not worse). As we get older the skin loses elasticity, and we lose the fat underneath our skin. This shows up as wrinkles, but for women this also results in a thinning of the skin of the vulva and the surrounding tissue becomes more prone to tearing.

Having sex prolongs life. If sex were a pill, it would be the most successful pill for increasing life than anything else on the market

Older women lose the ease of lubrication when aroused, so it might take longer for the vagina to become wet during sex. In most cases both of these factors result in small tears in the skin of the vagina, making the physical act of penetration painful and later prone to infections.

There are also changes overall. There might be pelvic organ prolapse when the muscles and tissues supporting the pelvic organs (the uterus, bladder or rectum) become weak, allowing for these organs to drop and press into or out of the vagina; not exactly a condition that promotes exhibition and a desire for sexual gratification. In addition there is urinary incontinence.

In 2015 the Brazilian researcher Renata Reigota and her colleagues reported that half of older women of an average age of 64 who had multiple births and a sedentary lifestyle (without much exercise) had urinary incontinence. The researchers report ed that most of the conditions that cause incontinence among women can be re­duced. Even having adequate preventive measures, the fear of leaking does not lend itself to amorous advances. Again, in these cases, desire is not a psychiatric condition but a realistic reaction to a changing body.

In heterosexual relationships, on the other side of the bed, there is the older man. After the age of 50, men’s erection becomes weaker and not as rigid. Ejaculation be­comes less productive and the burst less powerful. Refraction period, the time it takes for the penis to become rigid again after ejaculation, is delayed or disappears.

Men have no menopause but they have prostate problems to contend with. The little bulb that sits in front of the rectum secretes fluid that nourishes and protects sperm. In older men the prostate become enlarged (which can be either cancer or non-threatening). In most cases when it is cancerous, surgery involves either removing it or implanting radioactive pellets to kill the growth.

Prostate cancer is the most common non-skin cancer among men worldwide and, after lung cancer, is the second leading cause of deaths. Every year in the US, for every 100,000 men, 99 men develop new prostate cancer and 19 die.

Prostate surgery is complicated by the fact that the prostate is surrounded by tissue connected to all the organs in the groin. However careful, the surgery in­variably cuts nerves that have other functions that can result in erectile dysfunction, urinary incontinence, a reduction in penis size and dry ejaculation.

There are also complications when the lymph nodes are removed, in that fluid collects in the legs or genital region, causing swelling and pain. Again, this condition can result in a lack of sexual desire unrelated to psychiatric issues. It seems that psychia­try is following Sigmund Freud’s directive and ignoring older age. Since all of these physical issues become more common as we get older, it is surprising that older adults have sex at all.

With these changes there are also the psychological effects, as most older people see their body as less attractive, also reducing desires. To make matters worse, even our skin shows marks of older age. Laube Farrell in 2002 reported that by the age of 70, approximately 70 per cent of older people have at least one underlying skin problem. While Troy Kish and his colleagues with the Veterans Affairs Medical Centre, Bronx, New York, identified that the primary infection is staphylococcus aureus, followed by streptococci, shingles, diabetic foot infections, infected pressure ulcers and scabies. Some of these skin infections can kill you.

These individual body changes come together to form the dance that we discussed earlier. Although this might involve heterosexual couples, homosexual couples are similarly affected. With tears in the vagina and lack of lubrication, penetration for women can become very un­comfortable. The man realises this and thinks that it is due to his diminished erection and his lack of power. In return, the woman sees that the man is not rigid enough and blames herself for being unattractive. Both partners, as a result, disengage. This is the dance most couples fall into; assigning blame to themselves for changes in the other that they have little control over.

The main sex organs in the body are the brain and your skin. Sex can utilise these organs so that we become intimate with other parts of our bodies. Use what works.

Intimacy is all about allowing someone else to have privileges with our bodies, and communication is the best way to explore what those privileges are. Communication is the best foreplay.

Mario Garrett was born in Malta and is currently a professor of gerontology at San Diego State University in California, US.

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