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Sex and the older couple

Written by Regina Koepp

An older couple looks at each other and smiles as they eat a picnic in front of a tree

My 87-year-old client Cliff, who uses a rolling walker and is hard of hearing, has a penchant for plaid button-down shirts—and sexual bondage. In an early session, I had to shout to ask him, “When you watch your BDSM porn, who do you identify with more, the sadist or the masochist?”

“Both,” he answered loudly yet calmly, as his wife, Lorena, shifted in her seat.

“I see,” I said. “Tell me more.”

In earlier sessions, Cliff and Lorena had admitted to struggling with communication difficulties during their 55-year marriage. Lorena prefers being direct; Cliff, not so much. He has a laissez-faire personality, while she’s organized and task oriented. As we talked about their dueling sexual preferences—BDSM versus missionary-style—I was curious about how their intimacy dynamics were reinforcing the wedge that had grown between them in their later years, and how we could work to resolve them.

As someone who’s specialized in working with older adults for more than 15 years, I’ve come to understand that other practitioners may not delve as quickly as I do into the sex lives of octogenarians. Like many in the general population, plenty of therapists have internalized the common misconception that at a certain point in our lives, humans are no longer interested in sex and intimacy. But much like Cliff and Lorena, many of my older clients are keen to maintain sexual connections.

A recent survey in Clinical Gerontologist echoes this reality. It found that about 50% of men and 30% of women between the ages of 65 and 80 remain sexually active. Yet fewer than a fifth of older adults regularly speak to their health care providers about their sexual health; and of those, the vast majority have to initiate the conversation themselves. It turns out that by avoiding “the sex talk” with older adults, we professionals are playing a significant part in ensuring that sexuality and aging remain a taboo—even invisible—topic.

I work to counter this taboo in my practice and, like any couples therapist, I always ask about my clients’ sex life, no matter what their age. But I’ve worked with many clinical trainees who are reluctant to broach the topic with this population. When I ask why, they’ll say, “That’s private” or “If it’s important, they’ll tell me.” Sometimes they even say something overtly ageist like, “Is sex really that important at their age?”

The truth is, a dearth of mental health professionals are trained in older adult issues or willing to work with this population. Even I had my own ageist indoctrination to contend with. For a time, I struggled with publicly claiming my professional identity as a psychologist who specializes in older adults. I feared that people would see me as out of touch and no longer cool—in essence, “old” myself. But after much reflection, I realized that I was internalizing ageist messages from a society that tends to devalue people as they get older.

Don’t assume your older client is straight

Please be advised that this section mentions suicide. If you’re in crisis, help is available now: Call the free, confidential 988 Lifeline at 988 or 1-800-273-TALK (8255).

Helping trainees and other professionals discover just how harmful ageist thinking is can feel like a Herculean task, especially when the topic of sex is broached. Researchers have found that the general public views sex among older adults as shameful, disgusting, laughable, and even nonexistent. This alone can lead older adults to internalize sex stigma, resulting in an increase in sexual problems in their lives.

I believe we can shift the narrative about aging and sexuality toward a more accurate and holistic view. After all, there are many documented benefits to sexual relationships over age 50, including better heart health and a greater sense of attachment and belonging. There’s also a link between frequent sexual relations and scoring better on cognitive tests. Plus, sex improves mood in older adults and can even provide a spiritual lift, in some cases heightening a sense of meaning and purpose.

But don’t just assume your older client is straight. The intersection of discrimination experienced by older LGBTQIA+ adults and ageism can be profound. In fact, studies show that many older LGBTQIA+ adults fear having to re-closet themselves when moving into a long-term care community. When the time does come to move, many choose to hide their sexual orientation. The experience of transgender older adults is even more dire, with studies showing that many older transgender people prefer death by suicide to moving into a long-term care community.

Once, in the span of six weeks, two older adults married to spouses of the opposite sex, with whom I’d been working in individual psychotherapy to manage their depression and anxiety, revealed to me that they’d had same-sex relationships earlier in their lives. While they loved their spouses, they feared their lives would end without experiencing that kind of deeper love again. We spent several sessions processing the suffering that LGBTQIA+ phobia had caused them, grieving the missed opportunities it had meant for them, and creating a space where they could be seen and valued for who they are. As therapists, it’s on us to help repair some of the damage that has been done to LGBTQIA+ folks excluded from communities then and now.

Changes in the body over time

Whatever our clients’ sexual orientation, supporting their sense of themselves as sexual beings in later life is important. But as we do this, we need to acknowledge the physical shifts that occur with age. For example, their bodies will experience menopause and andropause, and these changes may lower their sex drive.

For women, hormonal shifts, as well as structural changes in the vagina and in the body’s ability to lubricate the vagina, can result in a reduction in sex drive. Because these changes can make certain types of sexual activity painful, such as vaginal penetration, many women find lubricants beneficial, and some work with their doctors to use hormone therapy to treat menopausal symptoms and intensify their sex drive.

For men, andropause, the natural lowering of testosterone with age, may result in a drop in energy and desire, erectile problems, less muscle mass, trouble focusing, and mood changes, including increased irritability. I’ve found that some older men with suboptimal levels of testosterone have had a positive experience using testosterone replacement to increase their sex drive.

A decline in libido may be related to medical issues, mental health issues, or medications used to treat medical and mental health issues. I always encourage clients to work with their doctor to discuss sexual side effects of medications, and I readily help them manage the common problem of one partner’s sex drive having changed over time while the other’s hasn’t.

Dealing with sex drives

Recently my 68-year-old client Jerome, who was experiencing erectile dysfunction following surgery to treat his prostate cancer, was grieving the loss of intimacy with his wife, Sondra. He wanted to share his feelings with her but was afraid of appearing “less than a man” in her eyes. Naturally we explored his perception of “being a man,” processed his grief, and even role-played the conversation he’d have with his wife. In the end, he found that she wasn’t as affected by the change in their sex life as he feared she’d be. He was projecting his own feelings of inadequacy onto her, when in fact she continued to enjoy the physical affection that they shared without intercourse.

This dynamic is reflected in a recent study that looked at couples in which one partner was living with Parkinson’s disease, a condition that strongly affects sexual health and sex drive. Although both partners desired intimacy, they were now less apt to express it. And interestingly, it wasn’t the partner but the person living with Parkinson’s disease who was the most dissatisfied with their sex life.

Whatever our older clients’ health challenges, the more we can help them adjust to illness and communicate about their intimacy needs and goals, the better. Intimacy can’t cure their medical problems, but it can help a couple stay more connected throughout these changes.

When I was helping Jerome process the changes in his sexual relationship with Sondra, I first helped him grieve the loss of sex in his life as he once knew and enjoyed it. We dove deep into society’s expectations of men when it comes to sex and vitality, and we worked on adjusting his “sex-pectations”—changing the focus from what his body can’t do to what it can. I helped him broaden his view of sexual intimacy to include oral sex, fondling, and fantasy talk, and we explored the value of many other forms of intimacy, from affectionate touch to emotional vulnerability to reminiscing about the most connected and intimate times in his relationship. Over time, Jerome began to accept his body and described a deeper connection with Sondra.

When older clients want to talk about boosting their sex drive, which many do, I often start with basic recommendations about eating well, because the healthier your body, the healthier your libido. Studies show that exercise also correlates with a higher sex drive and better sexual function. In a similar vein, adequately managing stress is important because it’s easier to get in “the mood” from a relaxed state. I encourage my clients to pay attention to when they’re at their best (physically, emotionally, energetically), and prioritize intimacy during these times. But no matter what, communication is key. I tell my clients, “If you’re noticing changes in your body, so is your partner. It can help to talk about it.”

Helping partners reimagine desire

Finally, one of my favorite discussions in psychotherapy is to encourage my older clients to get creative when it comes to sex. I explain that a new physical disability or life-altering medical condition doesn’t have to mean the death of their sex lives. Sometimes it just means they have to become playful, not take each sexual encounter so seriously, and enjoy the process of finding new and more creative lovemaking experiences.

Cliff and Lorena were giddy in session several months after they’d explored Cliff’s preference for BDSM. On a recent vacation, they’d braved a visit to a resort drugstore to buy lubricant so they could enjoy a night of passion. It all went so well that it opened a new door to a closer connection. With improved communication and mutual understanding, they were able to meet each other in the middle. Cliff was willing to soften his expression of BDSM, and Lorena was willing to try new things.

In the end, they described feeling more intimate and connected than they’d ever been—which turned out to be bittersweet for them. Lorena described feeling a sense of gratitude while also experiencing grief over decades of missed opportunities in their marriage. Cliff, who’d been quite lonely in the marriage, felt more understood by and connected to Lorena, but also experienced a heightened, visceral sense of fear when it came to the prospect of losing her to breast cancer, which she’d already survived twice.

Cliff and Lorena may never have enjoyed their newfound intimacy if they’d faced a standard of care that makes sexual health a taboo after a certain age. As mental health professionals, we have an ethical and moral imperative to improve access to mental healthcare for all members of society and to challenge the barriers that keep people out of treatment. For our older population, this includes being willing to talk about sex and intimacy in new ways.

Regina Koepp, PsyD, ABPP, is a board-certified clinical psychologist, founder of the Center for Mental Health and Aging, creator of the only dementia and sexual health certification program in the United States, and lead medical psychologist at the University of Vermont Medical Center.

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