Factors Associated With Sexual Health and Well Being in Older Adulthood

Maria Kleinstäuber


Curr Opin Psychiatry. 2017;30(5):358-368. 

In This Article

Most Recent Findings on Factors Associated with Sexual Well Being in Older Ages

Mental Health Status and Depressive Symptoms

Mental health status and especially depressive symptoms have already been demonstrated to be associated with different dimensions of sexual health in older adulthood in previous research. These findings have been confirmed and extended in several recent studies, which are summarized in the following.

Park et al.[38] studied the relationship between sexual functioning and mental disorders. The authors showed for a representative sample of 3828 Korean women (aged between 50 and 74 years) that being diagnosed with a mental disorder was associated with a 2.7-fold increase in the probability of having a sexual dysfunction. The authors also demonstrated that in the subgroup of women with sexual dysfunction, the diagnosis of a comorbid mental disorder was significantly related to a relationship status of being unmarried, to an increased loss of pleasure in everyday life and to a history of sexual dysfunction before the age of 50.

Wang et al.[39] confirmed in a sample of 606 community-dwelling adults aged between 50 and 99 years (and living in a current partnership) a negative association between depressive symptoms and different aspects of sexual health, even after adjusting for age, physical functioning, anxiety, cognitive ability or perceived stress, in both men and women.

In a sample of 1548 women with a mean age of 71 years and of whom 53% lived in a partnership, 14% suffered from a hypoactive sexual desire dysfunction (HSDD).[40] HSDD is defined as a lack or absence of sexual fantasies and desire for sexual activities, which is usually associated with marked distress and interpersonal difficulties.[41] Typically, individuals experiencing HSDD do not initiate or do not respond to their partner's desire for sexual activity. Factors that were independently associated with the experience of HSDD in the mentioned study[40] were a relationship status of being partnered, experiencing vaginal dryness during intercourse, having symptomatic pelvic floor dysfunction and moderate-to-severe depressive symptoms.

An important extension of findings from previous research with regard to the relationship between depression and sexual health are results from a study by Freak-Poli et al.,[5**] who demonstrated that for participants living in a partnership, greater positive affect and life satisfaction were associated with higher levels of sexual activity. The authors conducted a secondary analysis of data from the Rotterdam Study,[42] which is an ongoing population-based prospective cohort study with the primary goal of examining the onset of disease in older adults. In a sample of 2273 older people with a mean age of 75 years (59% women), the authors demonstrated that although a well-validated self-report measure of depressive symptoms (Center of Epidemiological Studies Depression Scale, CES-D;[43]) was negatively related to sexual behaviour within partnered older adults, the negative affect subscale of CES-D showed no association with sexual behaviour. However, the CES-D positive-affect subscale and a self-report measure of life satisfaction were positively associated with sexual activity and physical tenderness. Positive and negative affects were mutually adjusted for each other and the relationships were controlled for physical health and chronic disease status and were observed for both sexes at all older ages.

Another important study on sexual health and ageing is the English Longitudinal Study of Ageing,[44**] which can be considered as one of the most influential general population studies of sexual activity and function in older ages of the last 2 years. In this study, several findings from previous research were replicated with a large sample (N = 6201 participants with a mean age of 67 years; 56% women). For example, data showed a decreasing sexual activity with increasing age; however, women were more likely to be sexually inactive than men. Moreover, poorer general health was related to lower levels of sexual activity and higher prevalence of sexual dysfunctions. The authors of this study also showed that difficulties in sexual functioning and disagreements with a partner about initiating and/or feeling obligated to have sex were associated with greater dissatisfaction with overall sex life. Regarding sexual satisfaction, sexually active men reported higher levels of sexual dissatisfaction over all ages than women did. The mentioned results were adjusted for the level of sexual activity.

Further Psychosocial Factors

In the following, recent studies are summarized that focus on factors associated with sexual well being in older age that have not been researched in previous studies. In a study by Estill et al.,[45**] for example relationships between sexual activity in older adulthood and the subjective age and attitudes about ageing were investigated. The authors reanalysed data from two waves of the Midlife in the United States Study. From the first wave, a sample of 1170 participants with a mean of 54 years was taken which was reassessed 10 years later in the context of the second wave. The effects of subjective age and attitudes about ageing on the frequency of sexual activities, the perceived quality of sexual activities and the interest in sexual activity over 10 years were examined. The authors demonstrated that neither factor – subjective age or attitudes about ageing – were associated with the frequency of sexual activity. However, authors showed that the older participants felt and the less positive their attitudes towards ageing were, the less satisfying they found sexual activity. The subjective age, but not the attitude of ageing, was significantly negatively associated with sexual desire.

In a study by Hartmans et al.,[3] the relationship between cognitive functioning and sexual health was investigated. A large population-based prospective cohort of 1908 adults aged on average 71 years (54% women) from the Longitudinal Aging Study Amsterdam was examined in a cross-sectional analysis. The authors of the study investigated how older people perceive their sexuality with regard to pleasantness and importance. The results showed that the worse the immediate memory recall of participants was, the more unpleasant they rated their sex life. The authors of the study interpreted these results in the sense that memory problems are often reported with increased age and especially in dementia. Impaired memory might indicate that perceiving sexuality could become complicated and the risk of misinterpreting feelings increases.

Another study focused on the association between religion and sexual health in older age groups.[46*] Iveniuk et al. [46*] used data from the National Social Life, Health and Aging Project (NSHAP), which is an influential nationally representative survey of older adults in the United States. The authors applied latent class analysis to a sample of 3005 participants aged 68 years on average (52% women) and established a composite measure of religious influence on sexual expression. The latent class analysis revealed two groups: a group of people with a high influence versus a group with low influence of religion on sexual attitudes as well as behaviours. Authors showed that religious influence was associated with higher self-reported satisfaction with frequency of sex, as well as higher physical and emotional satisfaction with sex, but only for men. The results were adjusted for demographic characteristics, religious affiliation, church attendance, intrinsic religiosity, political ideology and functional health. Moreover, results indicated a diversity of religious influence on sexual expression within faiths.

Stroope et al.[47**] reanalysed a subsample of 1656 married adults aged 57–85 years (43% women) from the 2005 to 2006 NSHAP in order to investigate associations between the sexual relationships and marital characteristics in couples of older individuals. The authors identified three important findings. First, they found that individuals in first marriages engaged more frequently in sexual activities than remarried individuals. However, the order of marriage had no effect on physical pleasure and emotional satisfaction. The second important finding was a 'U-shaped' relationship between marital duration and frequency of sexual activities, but not physical pleasure or emotional satisfaction. The frequency of sexual activity decreased with increasing marital duration until the age of 50 years. After the age of 50 years, it increased slightly with marital duration. Finally, authors also found a linear relationship between marital duration and frequency of sex, which, however, differed between women and men. According to the concept of habituation, an increased marital duration was associated with lower levels of sexual activity for women and men. At the same time, the sex-related gap which indicates that men are sexually more active than women and which has already been demonstrated in many previous studies (e.g.[48]) was demonstrated, however, mainly at low levels of marital duration. The sex-related gap in sexual activity seemed to diminish at relatively high levels of marital duration. This effect can be probably explained by two issues: sexual activity of men is strongly related to their health status[13] and older men tend to be married to younger rather than older women.[49] It is possible that in long-lasting marriages, there is a greater likelihood for women to be married to men who are healthier, whereas in shorter duration marriages the older men who women are married to have a greater chance of being unhealthy.

Health-related and Cultural Factors

In a recent study by Charandabi et al.,[50] the association between sleep disturbances and sexual activity was examined. In an Iran male sample of 290 participants with a mean age of 61 years, the authors demonstrated that different kinds of sleep disturbances (e.g. difficulty falling asleep and feeling tired despite enough sleep) were associated with a lower sexual desire, and with erection and ejaculation difficulties. However, these results have to be interpreted cautiously as they were not adjusted for demographic and other relevant variables. Moreover, the sample is not representative as it was recruited in one city in Western Iran and is therefore not representative for the general population in Iran. This study and its limitation prompts the question of how important it is to consider cultural differences in the research of factors associated with sexual activity across all ages. This problem is especially relevant for studies that are based on samples from nations integrating people from different cultural backgrounds or ethnical groups – especially the United States. In a recent study by Hughes et al.,[51] in a sample of 807 women aged between 61 and 89 years, the prevalence of sexual dysfunctions was examined. The authors could demonstrate that, for example, non-Hispanic white in contrast to African American women reported more lack of sexual interest (non-Hispanic white: 44% versus African: 31%) and more problems with vaginal dryness (non-Hispanic white: 42% versus African: 23%). Although the odds ratio did not reach significance, with regard to all other investigated sexual dysfunctions (e.g. vaginal pain during intercourse, sex is not pleasurable and inability to climax), the non-Hispanic white women reported a higher prevalence than the African American women.