Download interested in sex?

Sexuality in later life:
The older couple – interested in
sex?
Ms Claudine Domoney MA MBBChir MRCOG
Consultant Obstetrician and Gynaecologist
Chelsea and Westminster Hospital, London
Chair of the Institute of Psychosexual Medicine
Life expectancy UK 2004
C Domoney - BGS Aut 09
WHO 1978
Sexual health is a state of physical,
emotional, mental and social wellbeing in relation to sexuality;
it is not merely the absence of
disease, dysfunction or infirmity.
C Domoney - BGS Aut 09
Tuesday, Oct 06 2009
C Domoney - BGS Aut 09
Pam, 68, said: "We're more experienced,
more mature and more confident and we're
able to talk about what we want which
makes us better lovers."
C Domoney - BGS Aut 09
C Domoney - BGS Aut 09
Training of health care professionals
involved in care of older people
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Practice nurses
GP
Continence advisors
Physiotherapy
OT
Nurses
Physicians
Surgeons
Medical students
C Domoney - BGS Aut 09
Masters and Johnson
model of human sexuality
C Domoney - BGS Aut 09
Intimacy based model of
female sexuality Basson et al
May not need/have spontaneous drive
orgasm cf -men
C or
Domoney
BGS
Aut 09
Male sexual dysfunction
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Desire disorders
Erectile dysfunction
Male orgasmic disorders
Ejaculatory disorders
„ Premature ejaculation
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C Domoney - BGS Aut 09
Female sexual dysfunction
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Desire disorders
Arousal disorders
Orgasmic disorders
Pain
Non coital pain
disorders
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Definitions
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What is normal?
What is abnormal?
Normal frequency and satisfaction rates
Age related factors
Dyspareunia and sexual dysfunction rates
What cultural differences/variables are
recognised?
C Domoney - BGS Aut 09
Relationships
National Sexual Attitudes and Lifestyles Survey 2001
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unmarried, cohabiting
couples sex x3 /wk
1st year of marriage
x3/ 2wks
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ages 33-45 x1/wk
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ages 45-55 x1/month
C Domoney - BGS Aut 09
Statistics
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US study age 18-59 •Ï difficulties with age
„ 43% women FSD
•Ð activity with age
„ 31% men
• 32 % > 60
Laumann et al JAMA 1999
• 56 % married women
•Married women > unmarried
•Increased satisfaction with
relationship
•Benefit for genital aging
C Domoney - BGS Aut 09
Sexual activity and age
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Variation amongst European
women country by country
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N = 601 age 45-60
Frequency intercourse only
significantly different factor
BMI
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Beckman et al BMJ 2008
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Dennerstein & Lehert Menopause 2004
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Australian cohort age 45-55
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FSD 42% Î 88% from early
to late menopause
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Revised study incorporating
personal distress ↓ rate
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Hayes, Dennerstein 2005, 2008
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Higher satisfaction
Less sexual dysfunction
More +ve attitude
2000-1 cf 1971-2
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Dennerstein 2003
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70 year old Swedish popns
Improvement in sexual
experiences over 30 year
period
57% vs 40% men happy
52% vs 35% women
Sexual debut <20
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52% to 77% men
19% to 64% women
C Domoney - BGS Aut 09
Sexuality and older people
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Research findings -cessation more likely to be
male driven – consistent for 40 years
Last 30 years? ×ejaculatory problems and
dissatisfaction cf ED (but phosphodiesterase
inhibitors)
Earlier sexual debut linked with more +ve
attitudes
Satisfaction increasing in women overall
BMJ Editorial Kleinplatz 2008
C Domoney - BGS Aut 09
Importance of attribute to quality of life
(Score 4-5 on 5 pt scale) in AARP Modern
Maturity Sexuality Survey 2004
56% feel satisfying sexual relationship important (62% in 1999 survey)
Less important to women and older groups
C Domoney - BGS Aut 09
Impotence in males in AARP Modern
Maturity Sexuality Survey 2004
31% completely or moderately impotent (increase from 26% in 1999)
Up to 60% in 70+
C Domoney - BGS Aut 09
Sexual attitudes in AARP Modern
Maturity Sexuality Survey 2004
• ¾ too much
emphasis on
sex
• 6/10 critical
part of
relationship
C Domoney - BGS Aut 09
Sexual behaviour: AARP Modern
Maturity Sexuality Survey 2004
C Domoney - BGS Aut 09
Sexual drive: AARP Modern
Maturity Sexuality Survey 2004
Significant difference between men and women not having
C Domoney - BGS
any sexual feelings > 70 yrs
Aut 09
Sexual activity by partner status: AARP
Modern Maturity Sexuality Survey 2004
Women without a partner significantlyCfewer
sexual activities
Domoney
- BGS Aut
09
Other data from AARP Modern
Maturity Sexuality Survey 2004
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Reduction in sexual
activity
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With medical condition
On prescription medication
Not having physically active
life
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Frequency of orgasm
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2/3 men
1/3 women
Younger > older
4% men same sex
partner, 1% women
2/3 satisfied with sex life
14% used medications to
treat sexual problem
(incl hormones)
C Domoney - BGS Aut 09
Sex information: AARP Modern
Maturity Sexuality Survey 2004
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Differences by race/ethnicity
Modern Maturity Sexuality Survey 2004
Satisfaction with sex life
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European perception of sexuality around the
menopause –Nappi & Nijland 2008
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Have you experienced a reduced
sex drive more so in the last few
years than any other time of life?
1805 women age 50 -60
1488 with partner
Telephone survey
Not more so
recently
19%
36% reduced sex drive
21% vaginal pain / dryness/
discomfort
>50% sample reported sexual
contact at least 4x/month
Don’t know
5%
Never
experienced
44%
Recently
experienced
32%
Most likely
Switzerland
61%
Most likely
UK 47%
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Differences between countries
Germany
54%
France 40%
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Netherlands 40%
European perception of sexuality around the
menopause –Nappi & Nijland 2008
Have you experienced vaginal pain/
dryness during sex more so in
recent years?
Not more so
recently
12%
Recently
experienced
20%
Don’t know
4%
Most likely
Italy
/Switzerland/
France 69%
Never experienced
64%
Most likely
UK 31%
C Domoney - BGS Aut 09
Worldwide survey of attitudes to sex and
problems in men and women.
Nicolosi et al Urology 2004
Men and women reporting intercourse
frequency of more than once a week
C Domoney - BGS Aut 09
Worldwide survey of attitudes to sex and
problems in men and women.
Nicolosi et al Urology 2004
Women and men with at least one problem, by world region
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Sex
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Increases length of life
Greater well being
Better relationships in general
Better immune system
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Normal effects of ageing
on the female
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Reduced arousal
Reduced sensitivity
Reduced orgasmic potential
Mucosal changes
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Dry, delicate, less elastic, painful/sensitive
Changes in skin, hair, body
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Urogenital atrophy
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NR
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Age 69
Met 1st partner for 20 years
Never anticipated problem
Penetration not possible
‘Vagina the shape of a pencil’
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6 health professionals later.....
Vaginal oestrogens
C Domoney - BGS Aut 09
Normal effects of ageing
on the male
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Reduced arousal
Decreased sensitivity
Reduced ejaculatory volume
Increased resolution phase
Decreased penile angle
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Medical history
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General health and well being
Approach to ageing
Medical disorders incl mental health
Surgery
Pelvic floor disorders
Drug history
Alcohol/ smoking
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Medications impacting on sexuality
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Antidepressants and mood stabilisers
Antihypertensives
Cardiovascular drugs
Statins
„ Digoxin
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Hormones or antihormones
H2 blockers
Anticonvulsants
C Domoney - BGS Aut 09
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Contribution of the
diminution of the
senses
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Sight
Speech
Smell
Touch
Hearing
C Domoney - BGS Aut 09
Why do we not find those who
want or need further help?
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Fear of health professionals
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Can of worms
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No ‘specialist’ to refer to
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Patient expectations
C Domoney - BGS Aut 09
What to ask?
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Are you in a sexual relationship?
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Do you have a partner?
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Are you sexually active?
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Do you have any difficulties?
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Are they a problem for you?
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Do you have pain during sex?
C Domoney - BGS Aut 09
If you don’t ask....
You won’t get
C Domoney - BGS Aut 09
Physician enquiry increases patient
reporting of sexual dysfunction
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3% spontaneously
report
16% report after
direct questioning
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Screening for sexual
problems
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Bachmann et al 1989
effectiveness of 3 simple
screening questions
compared to detailed
interview by sex therapist
Three simple questions
yielded same results as the
detailed therapist interview
Plouffe L, Am J Obstet Gynecol
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3 non-intrusive questions
addressing:
Desire, Discomfort,
Satisfaction
C Domoney - BGS Aut 09
Physicians, patients and sexual
problems
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Pts experiences with
physicians management
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52% not ready to talk
about problem
76% not thorough exam
85% no diagnosis
87% no FU
Berman et al Fertil Steril 2003
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Hindrances for patient
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Too embarrassed
Not enough time
Would have if Dr initiated
Physician seemed too
rushed
Help
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Dr initiates
Dr comfortable
Dr Kind/inderstanding
Dr seemed concerned
Nusbaum et al Maturitas 2004
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Mid 60s
Treated for ovarian
cancer
Libido returned with a
vengeance
Concern regarding
recurrence
TH
Never make assumptions
about what sexual
feelings mean to an
individual
C Domoney - BGS Aut 09
Influences on sexual behaviour
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Abnormality
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Feelings about body
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Failure of arousal, fear
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Understanding of condition
and its treatment
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Feelings about genitals and
abnormalities
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Ignorance
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Operations
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Hormones
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Effect of pathology
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Effect of treatment
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Psychosexual problems
exacerbating physical
symptoms
Previous experiences
Key events
Understanding of ‘hidden
agenda’
Partners feelings and problems
C Domoney - BGS Aut 09
SP
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Age 74
Multiple pelvic floor operations
?motivated to continue with sexual activity
Brought husband
Sat looking like old man
We’re too old, its silly, its ridiculous at our age
Towards the end of the consultation starts to
get a glint in his eye – ‘ a naughty little boy
again’
C Domoney - BGS Aut 09
Sex
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A psychosomatic activity
Involves body and mind
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Psychosexual medicine
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= mind-body doctoring
„ Involves genital examination as ‘moment of
truth’
„ Use of the physical examination as a therapeutic
event
C Domoney - BGS Aut 09
AV Age 64
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c/o OAB
Interest in
questionnaire
Loss of sensation
Relationship
difficulties
Lack of control
Ultimate defence
Discussion lubricants
and E2
C Domoney - BGS Aut 09
NSF for Older People 2007
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listen to older people
respect their dignity and privacy
recognise individual differences and specific needs
including cultural and religious differences
enable older people to make informed choices, involving
them in all decisions about their needs and care
provide co-ordinated and integrated service responses
involve and support carers whenever necessary.
C Domoney - BGS Aut 09
Same sex relationships
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Difficulty in expressing
sexuality to carers
Little provision in
residential care
C Domoney - BGS Aut 09
Direct effects of disease or illness
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Neurological
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Genital
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Mobility
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Pain
C Domoney - BGS Aut 09
Safer sex
C Domoney - BGS Aut 09
Sexually transmitted diseases
in older people
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STIs in > 45 yr olds doubled in last 10 years
>50yrs 2000-2005
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Warts most common
X2 chlamydia
X3 HSV
HIV 0.7% to 2.2%
Increase in new partners in older age group
Less understanding of safe sex
Less/no need for contraception
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Opportunities
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Tourism
Internet
Speed dating
Cruises
C Domoney - BGS Aut 09
Residential care
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>500 000 people over 65 in residential
care
Long term needs
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Privacy
Dignity
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‘Expression of sexuality’
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Catheters
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Female and male catheters
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Consideration of suprapubic
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Penile injuries possible
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Positioning
C Domoney - BGS Aut 09
Erectile dysfunction
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1 in 10
2.3 million men in the UK
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× with age
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Causes physical and psychological
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Management of ED
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Phosphodiesterase 5 inhibitors
Hormones - testosterone
Penile rings
Penile scrotal rings
Vacuum devices
Injectable prostaglandins
Intracavernous
„ Intraurethral
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Vacuum constriction device in use
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Initiation of vacuum
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Pump removed, ring in place
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Constriction ring for use alone
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Penile rings
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Penile scrotal rings
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Three part inflatable prosthesis
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Three part prosthesis in-situ
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C Domoney - BGS Aut 09
BT Age 69
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Vault prolapse
Effect on sexual life
Sacrospinous fixation
Shortened vagina postop
Further procedure
Use of dilators
Collusion of both partners
C Domoney - BGS Aut 09
Female sexual dysfunction
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Psychosexual treatment
Hormones
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Systemic hormone replacement
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Topical hormones
Vaginal remoisturiser
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Oestrogen/ testosterone
(Replens MD –prescribable)
Lubricants
Sylk
„ Non water based
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C Domoney - BGS Aut 09
Hormones
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Topical oestrogen
Oestrogen
replacement
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Cyclical- non bleed
Testosterone
replacement
C Domoney - BGS Aut 09
Sexual aids
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C Domoney - BGS Aut 09
Lubricants
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Vaginal trainers/dilators
C Domoney - BGS Aut 09
PW Age 66
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Recurrent prolapse
Large rectocoele
Healthy sex life preoperatively
Postop
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Infection
Mesh erosion
Treatment with antibiotics and mesh removal
Given dilators & vaginal oestrogen
Rejected further psychosexual input
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–use natural dilator
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Elder abuse
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Concern for vulnerable adults
May have reduced ability to express abuse
Carers
Low threshold of suspicion
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Conclusions
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It is important for men and women of all
ages to feel they can discuss sexual issues
with their health care providers
There may have been changes in the
general population over time that increase
the importance of sexuality
Training is available for all!
C Domoney - BGS Aut 09