Age-associated changes in sexual activity

Sexual activity falls with age, but gradually, and it persists even in extreme old age; the asexual older person is a myth. Normal ageing is hard to separate from illness and psychosocial change.

UK survey, sexually active: men 84.5% at 60–69 years, 59.3% at 70–79 and 31.1% at 80 or over; women 59.9%, 34.3% and 14.2%. US survey, both sexes: 73% at 57–64, 53% at 65–74 and 26% at 75–85.

In the English Longitudinal Study of Ageing (ELSA, 50 and over), 852 of 2577 men and 1009 of 3195 women reported less desire than a year earlier.

India: a village survey near Mysore (259 people over 60) found 27.4% active (at least one intercourse in the previous year), falling from 47.6% at 61–65 years to 0% above 75. Among 60 Mumbai outpatients over 50, 83.4% of men and 43.4% of women were active. Samples are small and definitions of activity differ.

Interest outlasts activity (the "interest-activity gap"): in Mumbai, 52% of those aged 50–60 wanted sex at least weekly but 40% had it; over 60, 25.7% and 14.3%. Love and intimacy were unchanged or better for most (48% and 25%), and satisfaction need not fall with frequency, though 75% rated sex worse than early in marriage.

Men: desire falls; erection comes more slowly, needs more touch and is shorter; nocturnal erections lessen; ejaculation weakens with less fluid; the refractory period lengthens.

Women: desire falls; arousal is slower; lubrication is slower and less marked; the vaginal lining thins and may be sore; orgasms are fewer and less intense, but the ability to have one remains. Lower oestrogen after the menopause reduces lubrication and swelling, and estimates of post-menopausal dyspareunia range from 12% to 45%.

Testosterone matters for desire and arousal in both sexes. Slower response and weaker orgasm are not in themselves dysfunction: in Mumbai, reduced ejaculate volume did not distress most, and 71.4% of those over 60 were untroubled by weaker orgasm. Knowing the changes are normal and adjusting practice may prevent dysfunction.

Health: sexual problems become commoner with age but often reflect comorbidity more than age itself. In the British Natsal-3 survey (55–74 years), 26.9% of men and 17.1% of women said an illness or drug had affected their sex life; 23 interviews described capacity (erectile problems, pain), inclination (fatigue, depression), practicalities and fear of another heart attack or stroke.

Partner: among those affected, recent activity was over four times as high with a steady partner. Losing a partner weighs more on women, who outlive and are often younger than their husbands. In Mumbai, men cited desire, health or erections and women partner loss, yet 30% of women cited lost interest.

Drugs: antidepressants, antipsychotics, benzodiazepines, antihypertensives, thiazides, statins and anticonvulsants can impair function.

Attitudes: ageism, and myths that sex means only intercourse or that menopause ends a woman's sexual life. Indian barriers include shame, the belief that sex is for procreation, lack of privacy and children's disapproval. Authors differ on culture versus illness; most data are cross-sectional, so the balance is uncertain.

Ask: general practitioners often avoid the topic, thinking it irrelevant, fearing offence or lacking training, and only 28.6% of men and 20.5% of women with an affected sex life in Natsal-3 sought help. Assure confidentiality, use open questions, review drugs and do not assume a partner.

PLISSIT: Permission, Limited Information, Specific Suggestions, Intensive Therapy.

Treat a decline as a possible clue to illness. Over 4 years in ELSA, men with worsening erections had higher odds of incident coronary heart disease (OR 2.29) and cancer (OR 1.73, a first report; 1.49 after imputation), and women with less frequent activity of poorer self-rated health (OR 1.64; 1.38 after imputation). Direction of cause is unclear.

Avoid over-medicalising: some people accept having no sex life, and among affected Natsal-3 participants sildenafil use was not significantly linked with satisfaction, which tracked being active, relationship quality and partner communication. Many equate sex with penetration, so raise alternatives with tact.