Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Aging issues

Richard D Hayes, Lorraine Dennerstein

Introduction

Aging comprises a number of facets, each of which has the potential to affect a woman’s sexual function and dysfunction. Hormonal (see Chapter 5.5 in this volume) and physiologic changes (see Chapters 3.1-3.4) take place over the course of a woman’s life. Testosterone levels decline from a woman’s early 20s (see Chapter 6.3) and estrogen declines most rapidly during the menopausal transition (see Chapter 7.2). During puberty, pregnancy and postpartum hormonal and physiologic changes are particularly pronounced. Having and raising children, and relationship factors, including the presence of a partner, the partner’s age and sexual functioning, and the length of the relationship, each influence sexual activities (see Chapter 3.1). Her health and that of her partner will inevitably decline with age, and this will affect their sexual experiences. The use of medication tends to increase with age, resulting in a higher risk of side effects that may lead to sexual problems. Emotional and psychologic changes also occur with age. A woman’s priorities may alter, as may her feelings for her partner. The importance of sex in her life and level of distress she feels if she suffers from sexual dysfunction may also differ as a consequence of her age. The era in which a woman was born also has an impact, affecting her values and attitudes toward sexuality and her experiences.

Methodological issues

Information on the sexual changes that occur as women age can be drawn from both cross-sectional and longitudinal studies (see Chapters 2.1-2.4). Each methodology has advantages and limitations. Cross-sectional studies have the advantage of allowing a broad range of ages to be investigated with relative ease. However in cross-sectional studies, the effects of age and cohort membership are inevitably confounded. For example, a Danish study investigated 625 women who were born in 1958, 1936, or 1910 and found the percentage of women who never experienced an orgasm was greatest in the oldest cohort, while the percentage of women who had experienced spontaneous desire or desire after stimulation, or had ever masturbated was highest in the youngest cohort.1 We would expect that the longer a woman has lived, the greater the chances she would have had these experiences at some point in her life. Here we see the reverse trend, a result of social or other factors relating to the era in which the older women grew up.

Longitudinal studies are useful since they allow us to examine both aggregate trends and intraindividual patterns of change. We can see that in a given sample of women, patterns of constant, declining, and increasing sexual functioning are usually present. We can look at events that have precipitated these changes and see when they occurred. By being able to separate suspected causes and effects in time, we have stronger evidence for causation. One of the main problems in the literature on sex and aging is just how few longitudinal investigations there are. For many studies that purport to be longitudinal, either the recording or analysis of data relating to aging is crosssectional rather than longitudinal.2 For practical reasons, the length of follow-up is usually limited, so it can be difficult to establish whether the change in sexual functioning is an exception or is consistent with the overall pattern of sexual functioning in a woman’s life. Many longitudinal studies in this area focus on the menopausal transition, and often the age range included is very limited for this reason, or the data are analysed by menopausal status rather than age.

Cross-sectional studies

Sexual activities

The vast majority of studies indicate a decline in the frequency of sexual activities with age.3-10 A community study of 9578 women aged 16-59 years who were sexually active (in masturbation or with partner) found that the frequency of sexual activities with a regular sexual partner was less in older women.11 On average, women in their late teens and 20s engaged in sexual activities 2.2 times a week, in contrast to 1.3 times per week reported by women in their 50s. There is also evidence that in the 60-85 year age group, this decline contin- ues.6,7 In the older age groups, there is also a smaller number of women who remain sexually active. In a national study in the USA, the number of women who report sexual activity with a partner peaked at 93% for women in their late 20s, gradually declined to 82% for women in their early 50s, and then declined more rapidly to 60% for women in their late 50s.8 In a British study of 2045 women aged 55-85 years, the number of women who reported being still sexually active was 46% for women in their late 50s to early 60s, and declined to 4% for those in their late 70s to early 80s.9 Kinsey et al.3 investigated differences in the frequency of sexual activities with age and noted differences between married and unmarried women (these differences are described in detail in the ‘Partner age, health, and sexual function’ section of this chapter). Most investigators do not distinguish between women of different relationship status when reporting differences in sexual activities with age. Research investigating women’s masturbation frequency indicates that the frequency of masturbation increases from the teen years through to the early 20s, after which it plateaus until around the mid-40s and 50s, when it starts to decline.8,10,12 Masturbation has also been found to be more common in women without a regular partner.12

Sexual functioning

In cross-sectional studies, although findings vary, the overall pattern of a woman’s sexual functioning is one of decline with increasing age. It is difficult to identify when this decline in sexual functioning begins. Most studies investigating sexual function do not include women under the age of 35,4'5'7'10'13'14 and those which do include younger women use broad age categories to analyze their data.15,16 The most we can conclude is that a woman’s sexual function starts to decline sometime between her late 20s and late 30s. There is general agreement in the literature that with age there is a decline in desire1,16 and sexual inter- est.4,5,15,17 In addition, when older subjects were asked to compare their current level of sexual interest with that of their younger years, the majority reported a decline.7,18 A small increase in sexual interest in women in their late 60s and early 70s has been reported, but this was still in the context of an overall decline in sexual interest with age.4 A number of studies have demonstrated that the frequency with which women experience orgasm also decreases with age (see Chapter 6.4).5,16,18 Hallstromspecifically investigated orgasm associated with sexual intercourse, but usually the type of sexual activity involved is not reported.16,18 Research into changes in arousal with age is very limited. Arousal incorporates psychologic arousal, such as the subjective feeling of sexual excitement; nongenital arousal, which may be expressed as increase in blood pressure, flushing, or other somatic responses; and genital arousal, such as increased blood flow to the genitals and increased vaginal lubri- cation.19-21 Of these aspects, more often than not, it is only vaginal lubrication that is investigated. There are reports of arousal both decreasing with age16 and remaining constant.10

Sexual difficulties and dysfunction

For the most part, the number of sexual difficulties and dysfunctions women report remains fairly constant with increasing age, the exception being sexual pain, which appears to decrease. There are a few reports of sexual desire problems either increas- ing22,23 or decreasing24 with age. However, most community-based studies which ask specifically about problems with sexual desire or interest show no relationship with age,2,25-28 even though, collectively, these studies span an age range of 18-96 years. This is surprising, since, as noted above, there is good evidence that sexual desire decreases with age,1,4,5,15-17 so one might expect problems of sexual desire to increase with age as a result. Studies where difficulties in achieving orgasm are investigated consistently show no association with age,22,24-29 with only a rare exception breaking this trend.23 When arousal problems are investigated, most studies focus on problems with lubrication, neglecting other aspects of arousal. The data on arousal problems are ambiguous, with a similar number of studies reporting an increase in problems,22,23 and no change with increasing age.15,17,26 Surprisingly, perhaps, most studies report that problems with pain during intercourse decrease with age9,10,23,26,28,29 or at least remain constant.24,27,30 Relatively few studies have investigated changes in vaginismus with age. One such study of women aged 18-65 years found no significant relationship between age and the proportion of women reporting vaginismus.27

Longitudinal studies

Frequency of intercourse and sexual interest/desire are the main outcomes considered in longitudinal studies which investigate the effects of age. Stability over time is the most commonly observed pattern for frequency of intercourse31,32 and for sexual interest or desire.31-33 There are also, however, reports of sexual frequency and desire declining with age.34,35 Studies which report patterns of stability also report patterns of increase and decline but in smaller percentages of the sample. Longitudinal studies also show that partner factors play an important role in changes in sexual frequency and desire over time.31-34

Factors associated with decline in sexual functioning with age

Length of relationship

The effect of increasing age on women with partners is confounded by the increasing length of the relationship. This is important because the amount of time a couple has been together has significant consequences for sex in the relationship. In 1981, William James investigated the rate of decline of coital rates with duration of marriage and identified a “honeymoon effect”: a rapid decline in the rate of intercourse during the first year of marriage.36 This was found to be true at least in couples who had no premarital sex. In this and a later study,37 James reported frequency of sexual intercourse halving in the first 12 months of a relationship, then halving again over the next 20 years. There is also evidence that some aspects of sexual functioning may decline with increasing length of relationship. The Fugl-Meyers’22 reported that sexual desire and interest decreased with length of relationship for women in their late teens to early 30s, and sexual desire decreased with length of relationship for women in their early 50s to mid-60s.

Partner age, health, and sexual function

In 1953, Kinsey et al. reported that the frequency of sexual activities remained constant in unmarried women up to age 55 years.3 In men, he found that sexual activities declined steadily from puberty onward. Married women, however, were found to have a similar pattern of decline to men. Kinsey concluded that declining frequency of intercourse and orgasm in marriage does not prove that the sexual capacity of a woman is influenced by her aging, but instead could be the result of her husband’s aging. In heterosexual couples, the effect of male aging on the relationship is enhanced by the fact that, on average, men are older than their partners.11 This is almost certainly the main reason that the frequency of intercourse reported is higher in males than females of the same age.32 As the woman ages, so, too, does her partner. As he ages, his health will inevitably decline. His use of medications will increase, as will the risk of negative side effects of these on his sexual functioning. His risk of developing a sexual dysfunction generally will increase as they both age.38 All of this will also happen to the female partner as she ages, but because, on average, he is older, it is most likely to happen to the male partner first. The era in which a woman’s partner was born will affect her partner’s attitudes toward sex and also influence their sex life together.18 These issues may help explain why women report significantly lower levels of sexual interest than their male peers.4,32

Reasons for ceasing sexual activities

Factors relating to a woman’s partner and the relationship as a whole are as important as her own sexual functioning in dictating when sexual activities in a relationship end. In some early investigations, men and women were asked why sexual activities had ended in their relationships. The majority of women blamed their husbands, and the majority of men blamed themselves.4,31,32 More recently, Blumel et al.39 conducted a clinically based study of 534 Chilean women aged 40-64 years and found that the reasons for ending sexual activities varied with age. The most common reason given for ending sexual activities was partner erectile dysfunction in women younger than 45 years, low sexual desire in women 45-59, and lack of a partner for women older than 60.

Other factors associated with decline in sexual functioning

There are a range of other factors which can affect a women’s sexual functioning and activities as she ages. In a study by Deeks and McCabe in 2001,38 sexual communication, measured on a scale designed by the authors, was shown to decrease with age. The scale used to assess sexual communication in this study incorporated a range of questions, including how active the woman is in sexual activity, how well a woman’s partner tunes in to what she likes, and how caring her partner is as a lover. There is also evidence that a woman’s feelings toward her partner may change with certain hormonal conditions which occur during her life, such as the menopausal transition.40 Reproductive changes and the menopausal transition have major influences on a woman’s sexual functioning and sexual dysfunction. These topics are discussed elsewhere in this text and are not the focus of this chapter, except to mention that reproductive changes and different menopausal states are inherently confounded with aging.

Factors associated with periods of improvement in sexual functioning with age

Although the exception rather than the rule, improvements in sexual functioning with age have been noted in both longitudinal and cross-sectional studies. Usually, a small percentage of women (5-15%) in longitudinal studies show an improvement in sexual frequency or functioning with age. It should be noted that the periods of time we are considering are very short. For practical reasons, longitudinal studies rarely have long periods of follow-up, so these improvements are not ones spanning youth to old age but more likely represent short periods of improvement in a general pattern of decline. Most studies suggest those who report increasing sexual interest are small in number and become steadily fewer with age.5 Caution should also be exercised in how we interpret these data to ensure that we are observing a real increase in sexual frequency or functioning, and not simply a shift in attitudes over time.

The effect of the novelty of a new relationship

Just as sexual frequency declines with length of a relationship, the forming of a new relationship usually results in an increase in sexual frequency. This positive effect of novelty on sexual frequency seems to be quite robust. In a community-based, cross-sectional study of 2001 women aged 45-55, 7% of women reported increased sexual interest compared with 12 months previously. This increase in sexual interest was most commonly associated with a new partner.41

Regression toward the mean

A longitudinal study in Sweden conducted in 1968-75 found that an increase in sexual desire was predicted by weak desire at first interview, reports of negative marital relations prior to first interview, and mental disorder at first interview.34 In a sample of 108 married women aged 46-71 years, 5% reported an increase in sexual activity over the 6 years of follow-up, but half of these had resumed sexual activities after a period of cessation.32 Why should these ostensibly negative experiences predict an increase in sexual functioning? One reason for the increase may simply be regression toward the mean. A further decline in functioning experienced by a woman who reports the lowest level on a scale will not be detected, and it is likely that at some point the factors contributing to her being at the lowest end of the spectrum will change. The result is an improvement in a woman’s sexual functioning to bring it more in accord with the majority of women her age. The regression toward the mean also works in the reverse direction, with high levels of sexual functioning predicting a decline over time.34

Healthy survivor effects

Interestingly in the oldest age groups, an increase in sexual functioning has occasionally been reported.4 This is most likely due to a survival effect, with sick, sexually inactive women dying and so no longer being included in the cohort, or their partners dying and renewed sexual activity taking place with a new partner.

Reasons for stability over time

As noted, stability over time is the most commonly observed pattern for frequency of sexual activities and for sexual interest or desire in longitudinal studies.31-33 Why should this be the case, given that the majority of cross-sectional studies1'4,5,7,15-18 and some longitudinal studies34,35 report that sexual activities and sexual functioning decline with age? For practical reasons, the length of follow-up is rarely much longer than 10 years. This restricts the ability of longitudinal studies to detect small changes that occur over larger periods of time and may mean that these changes are detectable only in some women. Most studies which report patterns of stability over time also report patterns of increase and decline in small percentages of the sample. Discrepancies between studies may also relate to the sensitivity of the instruments used. In addition, in older cohorts, a large proportion of those who show no change in sexual frequency or desire over time are women who are no longer sexually active or feel no desire.31 There is further evidence, however, that sexual activities and sexual functioning may be relatively resistant to change. Koster and Garde33 found current frequency of desire to be correlated with former sexual activity. More recently, Dennerstein and Lehert42 found that prior level of sexual functioning was the most important predictor of current sexual functioning. It is reasonable to conclude that for most women sexual function and activities are relatively stable over the short term, any changes taking place being quite small and difficult to detect.

The presence of a regular partner

A woman’s sexual activities are significantly influenced by the availability of a regular partner (see Chapters 8.1 and 8.2). In 1953, Kinsey et al. (see Chapter 1.1) investigated changes in sexual frequency with age and reported differences between married and unmarried women.3 In an investigation of 250 Caucasian and African-American men and women aged 60-93 years, Newman and Nichols43 found that 54% of respondents who were married were sexually active compared with only 7% of respondents who were single, divorced, or widowed. In 1990, Diokno reported similar findings for women aged 60-85 years. Feelings of desire and enjoyment of sexual activities are also affected by the availability of a partner, although studies disagree whether this is a positive or negative relationship. Koster and Garde33 found that the frequency of desire a woman experienced was positively correlated with partner availability. Conversely, in a study of woman aged 35-55 years, Mansfield and co-workers13 found that a decrease in desire for sexual activity was associated with being married, but not with current age, and a decrease in enjoyment of sexual activities was associated with increasing age and being married. The effect of other factors, such as the length of the relationship and changes in feeling for one’s partner, may be responsible for these conflicting results.

Sexual satisfaction, personal distress, and the importance of sex

Recognition that personal distress plays an important role in sexual dysfunction has increased in recent years (see Chapter 2.4). New definitions of sexual dysfunctions have developed which include personal distress as part of the definitions for vaginismus, desire, arousal, and orgasmic disorders.21 Only recently have validated instruments for assessing sexually related distress been developed.44 Thus, validated measures of sexual distress have rarely been included in epidemiologic studies. However, age-related changes in some aspects of sexual anxiety and distress have been investigated. Bancroft and coworkers explored distress about the relationship and one’s own sexuality in a group of 987 women aged 20-65 years.15 In selected comparisons, both forms of distress increased slightly with age; however, for the most part, there was no significant relationship with age. Laumann et al.26 found that anxiety about sexual performance decreased with age, and Richters et al.45 found that while anxiety during sex remained constant with age, worrying about attractiveness decreased.

Since most of the evidence points to sexual functioning declining with age,1,4,5,7,15-18 it is surprising that the proportion of women experiencing anxiety and distress does not rise with age in response to this. Some light may be shed on this by studies of changes in the importance of sex with age. There is evidence that as women get older the relative importance of sex may decrease.7,46 This age-related decline in the importance of sex may help explain why older women are not more distressed by poor sexual functioning and may also explain why the number of women who are motivated to report sexual difficulties does not increase with age.

Unlike sexual distress and sexual dysfunction, age-related changes in the levels of sexual satisfaction are more in line with changes observed in sexual functioning. Sexual satisfaction appears to decrease16,22,38,47 or at least remain at the same level with age.104"25

Conclusions

Overall, the number of women reporting sexual difficulties or dysfunctions remains fairly constant with advancing age. The exception to this is sexual pain disorders, which appear to decline with age. Sexual functioning and the frequency of sexual activities have been observed to decline with age in most cross-sectional studies. In longitudinal studies, this decline has also been detected, but patterns of stability and improved sexual functioning with age have also been observed for short periods of time. A variety of factors influence the changes in sexual functioning and frequency of sexual activities that occur with age. Among these, the length of relationship, partner health, partner sexual functioning, and feelings for partner are particularly important. While many women may become less sexually satisfied as sexual function declines with age, the decrease in the relative importance of sex with age may be one of the factors which allows them to be less distressed by these changes and less inclined to report sexual difficulties.

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