Blackburn J.A., Dulmus C.N. (Editors). Handbook of gerontology: evidence-based approaches to theory, practice, and policy

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issues, and sexual attitudes held by an individual become key variables explain-

ing the sexual lives of older persons (DeLamater & Sills, 2005; Gott & Hinchliff,

2003; Shaw, 1994).

TRENDS

In the decades since the publication of the Kinsey reports (Kinsey, Pomeroy, &

Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953), sexuality has been dis-

cussed more openly in the print and broadcast media, and recently on the Inter-

net. The widely held social construction of a sexless old age has begun to be

replaced by a new concept of aging well—an assumption that all older persons

“should be physically healthy and sexually active” (Gross & Blundo, 2005, p. 87).

Will this “emerging myth” (Gott & Hinchliff, 2003, p. 1627) ultimately prove as

controlling of older persons as its opposite has been? Will one stereotype be re-

placed by another?

The older persons who participated in past sexuality research were born prior

to the end of World War II. They came of age before the Sexual Revolution of the

1960s and in the absence of reliable information about sexuality.

The first of the 76 million baby boomers, born between January 1, 1946, and De-

cember 31, 1964, began turning 60 in 2006. These individuals “constitute the

largest number of persons ever born in a single generation from 1905 until the

end of the twentieth century in the United States” (Maples & Abney, 2006, p. 3).

As this large birth cohort of Americans becomes older persons, they bring with

them changing sexual beliefs, attitudes, and life experiences. The baby boomers

are a diverse group, despite the tendency of mass media to present them as ho-

mogeneous. The experiences of the oldest and the youngest of the generation are

vastly different. This generation has experienced an unprecedented rate of mari-

tal dissolution and the growing acceptance of gay and lesbian relationships

(Burgess, 2004). They have seen the development and marketing of oral contracep-

tives and the discovery and spread of the human immunodeficiency virus (HIV).

They have had access to more information on human sexuality than any prior

group. Even though their sexual attitudes and beliefs were socially constructed

in this milieu, research assessing their basic factual sex knowledge has found

most to be woefully lacking (Reinisch & Beasley, 1990). How will the life experi-

ences of this cohort influence their construction of sexuality? How will they un-

derstand relationships and intimacy? What similarities and differences will be

found between them and the men and women who preceded them?

Mass media have focused for 60 years on the baby boomers’ impact on Ameri-

can society as they moved across the life span. The media have catered to the as-

sumed needs and wants of these 76 million individuals through each stage of

their lives. Shifts in the content of popular media can be observed as the supposed

needs of the now older boomers are being addressed, despite little actual knowl-

edge of the enormous variety of sexual interests, desires, behaviors, attitudes, or

beliefs of this huge audience. These men and women are healthier, more affluent,

and better educated than any generation before them (Maples & Abney, 2006).

They are accustomed to being focused on as a driving force in society. In light of

the fact that this generation has experienced profound political power, it is likely

that they will be far less willing to accept the notion that their sexual expression

is invalid (Richard, 2002).

Sexuality and Intimacy 247

In recent decades the number of couples of all ages cohabiting without mar-

riage has dramatically increased, as has society’s acceptance of these living

arrangements (Strong, DeVault, Sayad, & Yarber, 2005). Although some older indi-

viduals will continue to sanction sexual expression only within marriage, more

will be sexually involved with partners to whom they are not married, and whom

they do not intend to marry, for a variety of reasons. Same-sex couples, who may

have been hiding their relationships for years, are living together all across the

country. Many of these couples, denied legal marriage in most of the United

States are only now openly acknowledging the true importance of their partners.

Increasing societal acceptance of same-sex relationships, particularly among the

young, will likely help couples of all ages to more freely express their sexuality.

Another ongoing societal process is the medicalization of sexuality. Sexuality,

particularly in older persons, has been increasingly seen as a health or medical

issue (Tiefer, 2004). Massive publicity on erectile dysfunction medications, such

as Viagra, Cialis, and Levitra, has further medicalized the discourse on sexuality

in later life (Gross & Blundo, 2005). Pharmaceuticals will continue to play an in-

creasing role in the sexuality of older persons because these oral therapies are

easy to use and private, making them attractive to a generation accustomed to

rapid medical advances and simple solutions available from their primary care

physician. These medications can have a dramatic effect on sexual functioning for

some and will likely continue to be prescribed for and experimented with by peo-

ple of all ages. Continued research on oral pharmaceuticals promises physiologi-

cal enhancement of the sexual lives of individuals and couples, including older

persons. Yet what influences all these processes will have on the social construc-

tion of sexuality and intimate relationships for this group of older persons of the

twenty-first century is still conjecture.

SEXUAL FUNCTIONING IN LATER LIFE

The human body develops and changes throughout the life cycle. Developmental

sexual changes occur in older females and males, and these changes need not pre-

vent the continued expression and enjoyment of sexuality, although some adapta-

tion may be necessary for most. In women, menopause, which marks the end of

the menstrual cycle and of fertility and a decline in the production of the hor-

mone estrogen, results in a slowing of the arousal response, thinning of the vagi-

nal walls, and decrease in vaginal lubrication (Sanders, 1999; Sharpe, 2004).

However, when women continue to engage in behaviors that arouse them sexu-

ally, whether alone or with partners, the vaginal sexual changes tend to be mini-

mized for many (Bachmann & Nevadansky, 2000), and the sense of sexual

satisfaction may remain the same (Sharpe, 2004). Testosterone levels in women

usually decline with age, but what level of this hormone is required for the con-

tinuation of sexual function and desire in any individual is not known (Kings-

berg, 2002).

Among the typical physical sexual changes for males associated with aging are

a slowing down of the erection response, especially to indirect stimulation; less

firm erections; a decrease in the force of ejaculation and in the quantity of semen

released; a lengthening of the time needed to experience orgasm; and a longer re-

fractory period, the time it takes for a male to again experience orgasm. Males

have no inevitable “male menopause” or “andropause” comparable to the female

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menopause, no decline in testosterone that can be shown to be caused directly by

advancing age, although the majority of older men experience a decline (Sanders,

1999). As with females, the minimum level of testosterone needed to sustain sex-

ual interest and function is not known. Men often remain fertile until the end of

life (Sharpe, 2004).

The physical changes in the body and its sexual processes do not occur without

context, however. What meaning do older persons place on these changes? In a so-

ciety that focuses on youth as the standard for strength and beauty, many people

in later life are influenced to develop a negative body image as they age. Males

often tend to focus negatively on changes in their sexual functioning, particularly

erection, and women to have concerns about their sexual attractiveness (Stimson,

Wase, & Stimson, 1981). Older adults may fail to appreciate the possible advan-

tages of the more leisurely approach to lovemaking that is available to the older

individual or couple. Appreciation for the person within the body may receive

more emphasis when one lives in an older body. The typical view of sexuality as

erection focused invites men to negatively appraise their sexual performance

when changes in erectile functioning occur. In time, their fears of being unable to

engage in intercourse in the same way as before may prompt some men to avoid

all sexual activities. Women may see erection changes as a sign that they are no

longer attractive, an idea that seems to them to be confirmed when their male

partner avoids sexual contact. Instead, both could benefit from framing the

change as an opportunity to expand their repertoire of sexual behaviors to in-

clude more than just the genitals, continuing to provide pleasure for themselves

and their partners (Deacon, Minichiello, & Plummer, 1995). Aging, in itself, does

not cause sexual dysfunction (Sharpe, 2004).

SEXUAL DESIRE

The literature on sexual desire in older adults is mixed in its findings. Varying

definitions of sexual desire across studies present a challenge in comparing one

piece of research with another. Some studies have not operationally defined de-

sire. Others have assumed that frequency of sexual intercourse is a measure of

sexual desire, ignoring desire that may go unfulfilled because of health problems,

negative attitudes, or lack of a partner. Gott and Hinchliff (2003, p. 1626) note that

in many studies it seems that the researchers assumed that “if older people are

not sexually active sex is not important to them.”

DeLamater and Sill (2005, p. 139), noting that no universally accepted defini-

tion of desire exists in the literature, defined sexual desire for their research “in

terms of cognitive events (sexual thoughts, sexual fantasies)” that motivate sexual

experience. Using data from the 1999 AARP/Modern Maturity Sexuality Survey

of persons 45 and older, they examined the association between sexual desire and

several biopsychosocial factors. They reported a decrease in sexual desire associ-

ated with aging in both males and females, but not until age 75 or older did half

or more of the participants report a low level of desire. The effects of the partici-

pants’ attitudes toward sexuality were more predictive of sexual desire than any

other factor measured. Significant predictors of continuing desire were rating sex

as important to oneself and to one’s relationship and, especially for women,

being in a relationship.

Little research has asked older persons directly about their sexual behaviors,

attitudes, or what sexuality means to them. Qualitative research is especially

Sexuality and Intimacy 249

suited to exploring such questions because it allows the participants to speak for

themselves. Gott and Hinchliff’s (2003) study of 21 men and 23 women in the

United Kingdom ages 50 to 92 explored, with both quantitative and qualitative

methods, how important sex was to the participants. They found that all those

who had a sexual partner placed some importance on sex. Those who reported sex

as unimportant said that if they had a partner or had better health, sex would be

important to them. Those in their 70s and 80s rated sex as less important than did

the younger participants, but barriers to sex, such as health problems of the par-

ticipant or the partner, or not having a partner, rather than age itself, were the at-

tributions presented. Sex was reported as more pleasurable and of more

importance compared with the past for a minority of these elderly participants.

INTIMACY AND SEXUAL POTENTIAL

Most people, including most professionals working with the elderly, think of sex-

ual desire as a hunger for sexual behavior, usually defined as (hetero) sexual in-

tercourse, followed by satiation after orgasm. Although the desire-as-hunger

model, often called sex drive and associated with hormone levels, presents a part

of the picture of sexuality, it overlooks the psychosocial aspects of the salience of

the partner and the relationship. A relational model prioritizes desire for the

partner, desire during sex, rather than simply desire for sexual activity itself. The

hunger model suggests that desire comes out of emptiness, an emotionally imma-

ture stance that pushes people to attempt to fill or complete themselves by fusing

with another. Schnarch (1991, 1997, 2002) encourages the definition of sexual de-

sire as desire for the partner or desire during partnered sexual activity of any

kind. This relational approach to desire leads to a more emotionally mature

stance for each of the partners, an understanding of self as filled with love for the

other rather than as empty and needing to be filled by the other. Desire in the

emotionally mature person comes out of fullness, wholeness, a faith in oneself as

powerfully loving and lovable, as complete and desirable, in and of oneself.

In an intensely erotic and intimate sexual experience, there is a powerful sense

of self and separateness combined with a profound awareness of deep desire for

and connectedness with the beloved partner—a paradox. Sexual expression from

this perspective leads to self-validated intimacy rather than other-validated inti-

macy, a more emotionally mature position. Self-validated individuals are confi-

dent of their worth even without confirmation by a partner, whereas the

other-validated need constant reassurance from others. Schnarch (1991) suggests

that reaching this position, reaching one’s sexual potential, rarely happens before

middle or late life.

How might sexual potential be defined? Is human sexual expression only

about successful movement through a sexual response cycle that ends with an or-

gasm? Is the pleasure of an erect penis, a lubricated vagina, increased heartbeat

and respiration, or muscle tension the only purpose? If one has experienced or-

gasm, with another or alone, has one experienced the essence of sexuality, of sex-

ual fulfillment, of sexual potential? What lies beyond orgasm? Is it possible to

experience profoundly intense eroticism and intimacy, a passionate, transcen-

dent sexual experience, without orgasm (Schnarch, 1991)?

Couples can be divided into three groups: the sexually dysfunctional, the sex-

ually functional, and the “blessed few” (Schnarch, 1991, p. 71). Dysfunctional sex

is characterized by overfocusing on the genital sexual response cycle and the sex

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drive model by an overanxious couple. Sex is seen as work. It lacks fun, playful-

ness, passion, and intimacy. Either partner may feel a “need” for sex rather than a

desire for the partner, or may feel no interest in sexual behavior at all, which he or

she experiences as inadequacy and the partner experiences as rejection. The cou-

ple may feel no real human connection during sexual activity, resulting in low

levels of excitement or fears of inadequate “performance.” These couples are usu-

ally not well developed emotionally. They lack a healthy balance between sepa-

rateness and togetherness in relationships and have difficulty distinguishing

between their thinking and feeling (Bowen, 1978; Kerr & Bowen, 1988). They may

be emotionally fused or emotionally cut off from each other. They may be either

excessively rational or emotionally reactive about their difficulties.

Biological factors such as low levels of hormones, illness, disability, or interfer-

ence from medications may also influence sexual interaction. Yet for humans, the

most important part of sexual experience is the meanings they place on it

(Schnarch, 1991, 1997, 2002).

Most individuals and most couples in committed relationships and marriages

experience functional sex most of the time. They want to have sex, they experi-

ence excitement and orgasm, and they define sex genitally. Over time, boredom

and a lack of freshness or sense of novelty are common problems in couples who

are not growing and accepting life’s changes. Their “need” for sex still comes out

of emptiness or partial emptiness. Each partner is focused on the desire for the

sexual act and the release from tension. Many couples settle for functional sex

rather than struggle with the hard work of filling their own emptiness by devel-

oping more self-confidence and emotional maturity. It takes well-developed hu-

mans who take responsibility for their own experience of sexuality to create

passion, to spark eroticism. As the older partners in a long-term sexual relation-

ship become more and more important to each other, they come to realize that, if

the relationship continues, one partner will likely have to bury the other and suf-

fer the intense pain that comes from the loss of a beloved partner. Out of lack of

faith in their ability to handle such pain, many couples hold back from loving too

completely, too well. Few couples use the sacredness of marriage and committed

relationships to grow themselves up, to increase their tolerance for such anxiety

(Schnarch, 1991, 1997).

Some couples experience sex as a transcendent spiritual encounter or connec-

tion with self, partner, and their God or the universe (Ogden, 1999, 2002;

Schnarch, 1991; Shaw, 1994). A model of sexuality based on spirituality is very

different from the traditional model of sexuality. It includes the physical and the

psychological as well as the meanings that each of these has for the individual. It

combines thinking and meaning making with intense feeling and ecstatic emo-

tions. It involves having developed enough emotional maturity to be able to let go

of the need to self-protect and to allow the self to be vulnerable. These couples are

able to experience giving, receiving, and taking in the sexual encounter as indis-

tinguishable from each other. These blessed few define passion as something far

greater than the usual definition of simple physical desire or lust. They feel a pas-

sion for the partner, for life, for the universe or God. This passion involves mind-

and brain-directed sex rather than genital- and hormone-driven sex. Sexuality

based on an individual’s spirituality is more about the meanings attached to sex

than about the actual physical behaviors involved (Ogden, 2002). Few couples

consistently experience the intense passion and eroticism of spirituality-based

sex—many may never have such experiences. Those who do have transcendent

Sexuality and Intimacy 251

sexual experiences typically are older couples in committed long-term relation-

ships (Ogden, 2002; Schnarch, 1997; Shaw, 1994).

Shaw (1994, p. 134) conducted interviews with 65 men and women ranging in

age from 50 to 92, asking, “To what do you attribute your present sexual growth

and maturity?” The individuals and couples selected were people who, by their

self-report, “seemed to be living life as fully and gloriously as their health per-

mitted whether alone or with a partner” (p. 134). One description of personal sex-

uality from this diverse group was the following from a 72-year-old: “I now

experience my fingers as increasingly sensitive instruments of exploration, as

radar alert digitals that can know the nibbling, grasping, undulating response of

her flowing excitement” (p. 136).

A retired couple noted:

We have been together for 43 years. The physical aspect of our marriage gets better

each year, I think because we can tell each other the truth in every situation that af-

fects our relationship. It isn’t always pleasant but it’s always lively. (p. 136)

Clearly, these older people conceptualize their sexuality relationally, as does this

participant, who described her relationship with herself:

At age 60+ I am a woman convinced that masturbation is the ongoing love affair I

can have throughout my lifetime. My relationship with myself is the only constant

I can count on. Husbands and lovers may come and go, but I am always here for my-

self. (p. 137)

Older persons who experience sexuality in this manner are likely in the minority,

yet their experience is as much a part of sexuality and aging as is the experience

of those who might be placed in the sexually dysfunctional or functional cate-

gories. Knowing that such transcendent experiences exist may prompt more cou-

ples and individuals to move toward fulfilling their sexual potential.

ACKNOWLEDGING THE SEXUALITY OF OLDER

PERSONS IN PRACTICE

Gerontology professionals and all who work with older persons are faced with

the same myths about sexuality that the elderly themselves encounter. They also

face the same lack of empirical information about the day-to-day sexual lives of

older people. Reared in a society that has denied that older adults are or can be

sexual—or more recently, almost seems to be insisting that they must be sexual—

both service providers and their clients often struggle to understand the meaning

of sexuality in later life. As the population ages, more programs are being devel-

oped to raise the awareness of professionals (Lacy, 2002). Basic sex education re-

garding what is known about elder sexuality is needed for those who serve older

adults. In addition, training in developing greater comfort with sexuality in later

life, in all of its many aspects, and improved skills in communicating about sexu-

ality have been called for (Bonner, 1997).

ECOMING

OMFORTABLE WITH THE

EXUALITY OF

LDER

ERSONS

Gerontology professionals are often influenced by society’s distaste for sexual

expression in the elderly (Blackwell & Hunt, 1980; Hillman, 2000; Hillman &

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Stricker, 1994; Nay, 1992). The discomfort service providers may experience when

encountering sexuality in older persons creates barriers that can limit the free ex-

pression of sexuality and intimacy in their older clients. Education about sexual-

ity in later life can be extremely useful to those who work with older persons, yet

knowledge alone may not be enough to change negative attitudes and to create

comfort. Learning the facts and dispelling the myths—myths that often lie out of

awareness yet exert a powerful influence on attitudes and behaviors toward el-

derly sexuality—can greatly increase familiarity and comfort for professionals

and staff when this learning is coupled with practice.

Why is it that so many physicians and nurses do not initiate conversations

about sexuality with their older patients, waiting instead for the patients to bring

up the topic themselves, or not even noticing that it has not been brought up?

Why do many caregivers in nursing homes continue to be embarrassed, fright-

ened, or amused by the sexual expressions of the residents? Why is it that some

social workers carefully assess all their clients’ needs except their sexuality

needs? Why are administrators often embarrassed when callers ask what provi-

sions their institutions make for the privacy of their residents to engage in sexual

activity alone or with others? Despite their best intentions, many who work with

the elderly still find themselves struggling with many complex thoughts and

emotions that interfere with their ability to be most effective with those they

serve. Language, both verbal and nonverbal, can either facilitate or close down

open communication about sexuality and intimacy. When discussion is limited,

the result is a client who has missed an opportunity to gain knowledge that can

improve her or his sexual life (Brock & Jennings, 1999).

How can physicians, nurses, therapists, counselors, social workers, caregivers,

and other service providers increase their comfort level? A good place to begin is

with an honest self-assessment of one’s personal attitudes and beliefs about sexu-

ality in the elderly.

Personal Self-Assessment The following questions constitute a useful self-

assessment:

• Can I actually picture a couple in their 80s enjoying passionate, vibrant sex?

• Am I just a bit resentful when I realize that some older couples have a better

sex life than I do?

• Am I comfortable with the idea of a woman or a man in late life masturbat-

ing to orgasm, self-pleasuring?

• How comfortable am I with the thought of an older couple giving and re-

ceiving oral sex? Can I imagine them experiencing passionate deep kissing?

• Do I assume that all the older people I work with are heterosexual unless

I’m told otherwise?

• Can I picture an older male couple or female couple enjoying their lovemaking?

• How do I feel about an older widow or widower having sex with a variety of

dating partners and not wanting to marry any of them?

• How easy is it for me to assess for sexually transmitted infections and

HIV/AIDS when interviewing an older patient?

• How easily do I initiate a discussion of the sexuality and intimacy needs of

my older clients?

• Do I feel secretly relieved when the topic of sex is not mentioned and reas-

sure myself that I am protecting the older adult’s privacy?

Sexuality and Intimacy 253

• How do I react when a “sexual situation” presents itself in my work with the

elderly?

• What does my silence, changing of the subject, not taking the hint, laughing,

or looking embarrassed communicate to my clients?

Once the gerontology professional knows the areas where personal growth is

needed, action can begin. Some service providers may wish to take a formal sex-

uality education course with an experiential component designed to provide

practice in developing greater comfort with issues of sexuality in later life. Others

may decide to engage in their own personal growth program, tailored to the

needs they have become aware of through self-assessment (Brock & Jennings,

1999). Those responsible for supervising the work of others serving older persons

may implement training programs (Bonner, 1997; Hammond & Bonney, 1985;

Walker & Harington, 2002).

Approaches to Increase Comfort and Skills To become better at comfortably pictur-

ing the sexual expression of older persons and accepting it as valid and healthy,

viewing videos depicting the elderly as sexually active can be very helpful. For

example, Moonstruck (Palmer & Jewison, 1998) includes a romantic, late-night

bedroom scene involving a couple in their 70s, followed by the playful, sexy

morning after as they work in their delicatessen. Wrestling Ernest Hemingway (T.

Black, Wizan, & Haines, 1993) features the very different ways that two older

men, one divorced many times and the other never married, experience and ex-

press their sexuality. Finnegan Begin Again (Frost & Silver, 1984) portrays the inti-

mate story of a man involved in May-December and then December-May

relationships. A group of older friends, all now widowed, is depicted in The Ceme-

tery Club (Brown & Duke, 1993), as each one experiences her sexuality in her own

unique way. Grumpy Old Men (Berman & Petrie, 1993) combines laughter and

tears in telling the story of three generations of men in two families. These are

only a few examples of many movies that feature older adult sexuality. Addition-

ally, sexuality education videos are available, such as The Couples Guide to Great

Sex over 40: Volume I (Carson & Wiley, 1995), which interviews a couple in their 60s

and features them enjoying their sensuality and sexuality, sharing a bubble bath

with candlelight, soft music, and wine.

Reading about the sexual lives of the elderly is also useful. Love, Sex, and Aging

(Brecher, 1984) reports, in their own words, the diverse responses to a nationwide

survey of 50- to 93-year-olds and features such quotations as the following from

an 82-year-old widow: “To be able to successfully masturbate in the later

years...gives one a continued feeling of being a person...still a woman, still a

man....It keeps a necessary spark burning which says, ‘I’m yet alive—all of

me!’” (p. 241).

Reading chapter 14 in Constructing the Sexual Crucible (Schnarch, 1991), which

includes the sexually explicit transcripts of the sex therapy sessions of a couple in

their 60s seeking help for the husband’s erectile dysfunction, can promote knowl-

edge about resolving sexual difficulties as well as increasing comfort with sexual

expression in later life. Such reading can help service providers gain a clearer pic-

ture of the variation in sexuality in late life.

Sometimes reluctance to talk openly with older persons stems from experi-

ences with one’s own parents as being unable to talk comfortably about sex and a

respectful desire not to offend or embarrass an older person. One 37-year-old

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woman interviewed about the sexual discussions in her home as she grew up

with her mother reported, “The information I got from her, more in an unspoken

way, was, this was something you didn’t really talk about. Bad, kind of” (Brock &

Jennings, 1993, p. 63). Another woman, age 34, noted that when, as a teen, she ini-

tiated a conversation about sex with her mother,

she would be embarrassed. You know—like say nothing or say, “I don’t know.” So

you just don’t put your parents usually in a position where you make them uncom-

fortable, out of respect—well, respect. You just think, “Well, this embarrasses her,

so I’ll just go ask someone else.” (Brock & Jennings, p. 63)

Yet the elderly often want open communication about sexuality with their health

care providers (Aizenberg, Weizman, & Barak, 2002). They hold back out of con-

cern that they will be labeled a “dirty old man” or be patronized as “cute” for

wanting a sexual life at their age. If they are single or widowed, they may worry

about being labeled immoral for wanting to express their sexuality with partners

or wanting to pleasure themselves. Many older adults will wait for the service

provider to open the topic or may talk around the issue or make sexual jokes,

looking for permission to say more. When the professional is able to pick up on

these hints from the client or comfortably initiate a sexual discussion, the older

person is often relieved and then able to gain the information and reassurance

needed (Brock & Jennings, 1999).

When service providers have concluded from their self-assessment that they

may be, at times, annoyed that “older folks do it better” (Cross, 1993, p. 9), they

might comfort themselves with the knowledge that older couples are reaping the

benefits of a lifetime of physical and emotional experience, often filled with a joy

and emotional maturity that allows them to be more relaxed and at ease when

making love. Recognizing the need to better understand one’s own sexuality as

an important part of being effective in working with older persons is a sign of ma-

turity in the professional (Hammond & Bonney, 1985; Katzman & Katzman,

1985). Gerontology professionals can explore the unresolved sexuality issues in

their own lives that may lead to discomfort in their work. Through reading books

such as Passionate Marriage (Schnarch, 1997), which addresses personal growth in

committed relationships, and through seeking sex therapy, relationship counsel-

ing, or other avenues to resolve their own sexuality issues, professionals can pro-

mote the development of their emotional maturity, whatever their age (Brock &

Jennings, 1999).

Those whose self-assessment indicates a need to become more comfortable

when discussing sexually transmitted infections and HIV/AIDS with the elderly

need to know that in the decade ending in 2003, the total number of HIV/AIDS

cases in adults 50 and over had risen from 16,288 to 90,513 (“Late Life Sex Ed,”

2003). The number of older women with HIV/AIDS had grown faster than that of

older men, and most women’s cases involved heterosexual contact (Levy, 2001).

Older women experiencing vaginal dryness may have more tears and abrasions,

putting them at greater risk of infection. When physicians and other health care

providers assume their older patients are not engaging in any sexual behaviors,

they miss the chance to educate and to properly diagnose HIV and other sexually

transmitted infections (“Late Life Sex Ed,” 2003). Older individuals can and do

engage in unsafe sex, whether knowingly or not, and need accurate information

and encouragement to protect themselves.

Sexuality and Intimacy 255

If one’s personal assessment points to discomfort or lack of knowledge about

sexual orientation variation, many resources are available, including the follow-

ing books: Gay and Gray: The Older Homosexual Man (Berger, 1995), Couple Therapy

with Gay Men (Greenan & Tunnell, 2003), Lesbians over 60 Speak for Themselves

(Kehoe, 1989), and The Lesbian Family Life Cycle (Slater, 1995).

Quam (1993) discussed a variety of sexual and relationship concerns that may

affect older lesbian and gay individuals. For example, many fear that their part-

ners will be turned away by professionals as outsiders rather than being accepted

as spouses, or that their families of choice may not be treated with the same re-

spect as families of origin or families of procreation. Deevy (1990) provided some

excellent suggestions for discussing these clients’ sexuality needs. Asking open-

ended questions such as “Who is most important to you?” rather than “Are you

married, widowed, or divorced?” (p. 37) is one of the many examples offered to

open space for older persons to be themselves if they wish to come out. Gerontol-

ogy professionals can reassure older gay and lesbian individuals who may have

spent a lifetime hiding their sexual orientation from a disapproving society that

they and their relationships are valued and respected. Altman (1999) noted that

homosexually oriented individuals may be isolated and invisible to service

providers, who seem not to realize that gay and lesbian people grow old too.

Ward, Vass, Aggarwal, Garfield, and Cybyk (2005) found that the homosexual

population in care settings is not acknowledged, rendered invisible by heterosex-

ist assumptions, or disapproved of or ridiculed. Yet on a positive note, research

has shown that for many the process of building a gay or lesbian identity in a re-

jecting society has helped in developing coping mechanisms that are useful in re-

sisting the stigma of aging (Altman, 1999; Sharpe, 2004).

Another way for service providers to become more comfortable and knowledge-

able about gay, lesbian, bisexual, and transgendered sexuality is to attend a meet-

ing of Parents, Families and Friends of Lesbians and Gays (P-FLAG). Most large

cities have a chapter where visitors are welcome. The national organization main-

tains an extensive website at www.pflag.org containing much useful information.

Often, learning more about some basic approaches used in communicating

about sexuality can greatly improve a professional’s effectiveness in working

with older persons. For those interested in improving their ability to communi-

cate about elder sexuality, one area to focus on is the client’s level of sexual lan-

guage (Brock & Jennings, 1999). People vary in the vocabulary they use when

discussing sexuality. At least five levels of language may be used: scientific lan-

guage (vulva, coitus, ejaculate, fellatio, cunnilingus), common discourse (womb,

breasts, having sex, oral sex), euphemisms (down there, marital relations, come,

thing, it), street talk (fuck, screw, jack off, knockers, going down on, pussy), and

childhood (wee wee, weenie, boobies). Matching the client’s level of language and

careful questioning by the service provider can ensure that each fully under-

stands what the other intends to communicate and can ensure greater comfort for

all. When the professional is shocked or repulsed by street talk or amused at the

use of childhood language, clients may refuse to talk further. These may be the

only terms that some older adults know, so it is the responsibility of the profes-

sional to offer acceptance and comfort with their ways of talking. Over time, it

may be possible to help clients develop a more varied and appropriate approach

to discussing sexuality (Brock & Jennings, 1999).

In opening discussions of sexual topics, it is useful to begin with the least sen-

sitive topic and to be as open, comfortable, and matter-of-fact as possible. The