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Topics in Human Sexuality: Sexuality Across the Lifespan Adulthood/Male and Female Sexuality

Introduction

The development of sexuality is a lifelong process that begins in infancy. As we move from infancy to adolescence and adolescence to adulthood, there are many sexual milestones. While adolescent sexuality is a time in which sexual maturation, interest and experience surge, adult sexuality continues to be a time of sexual unfolding. It is during this time that people consolidate their sexual orientation and enter into their first mature, and often long term, sexual relationships. This movement towards mature sexuality also has a number of gender-specific issues as males and females often experience sexuality differently. As people age, these differences are often marked. In addition to young and middle age adults, the elderly are often an overlooked group when it comes to discussion of sexuality. Sexuality, however, continues well into what are often considered the golden years.

This course will review the development of sexuality using a lifespan perspective. It will focus on sexuality in adulthood and in the elderly. It will discuss physical and psychological milestones connected with adult sexuality.

Educational Objectives

1. Discuss the process of attaining sexual maturity, including milestones 2. Compare and contrast remaining singles, getting married and cohabitating 3. Discuss sexuality in marriage including factors that lead to lack of marital satisfaction 4. Discuss marital or partnered sexuality including frequency of , common sexual acts, and masturbation patterns 5. Review physical and emotional factors in sex after . 6. Discuss infidelity, including statistics, behaviors, and risk factors. 7. Discuss factors related to aging.

Milestones in Adult Development

As in many cultures, the United States has various norms for sexuality. Adolescence is a time when teens try on many "sexual hats" in order to determine what is sexually pleasing. In the adolescent years, most adolescents are not engaging in partnered sexual behavior; solo masturbation is the most prevalent teenage sexual

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2 activity with rates as high at 43% of males and 37% of females (NSSHB, 2010). In early adulthood, people move toward mature, adult sexuality. Hyde and DeLamater (2013) term this a period of sexual unfolding, and include several factors in this process. First is the development of sexual orientation. A 2014 report on sexual orientation and health among U.S. adults published by the Department of Health and Human Services (Ward et al., 2014) Among U.S. adults aged 18 and over, 97.7% identified as straight, 1.6% as gay or lesbian, and 0.7% as bisexual. These distributions differed by both sex and age. A higher percentage of women identified as bisexual, a finding consistent with other documented estimates of sexual orientation. With regard to age, a lower percentage of adults aged 65 and over identified as gay or lesbian (0.7%) or bisexual (0.2%) compared with adults aged 18–44 (gay or lesbian: 1.9%; bisexual: 1.1%) and adults aged 45-64 (gay or lesbian: 1.8%; bisexual: 0.4%). These estimates are similar to other surveys.

The trend towards more mature sexuality can be seen in data from a 2010 Kinsey survey, which looked at sexual practices and partners. More than half the participants in the 2010 national sex survey ages 18-24 indicated that their most recent sexual partner was a casual or dating partner. For other age groups, the majority of study participants indicated that their most recent sexual partner was a relationship partner. Another task of adult sexual development is learning sexual likes and dislikes and effectively communicating these to a partner (Hyde & DeLamater, 2013). This is often a process of sexual experimentation, and healthy communication positively impacts sexual connection and satisfaction. Throughout the lifecycle, developmental milestones can affect sexuality. These milestones (sometimes referred to as “crises”) include: 1. Quarter-life crises: A quarter-life crisis typically occurs between the ages of 25 and 30. It often revolves around the challenges that arise from young adults newly living life on their own and feeling overwhelmed with new responsibilities; it can also happen after the birth of a child or if a person graduates from college and cannot find a job in their chosen field. 2. Mid-life crises: mid-life crisis include problems with work, trouble in a marriage, children growing up and leaving the home, or the aging or death of a person’s parents.

• a search for an undefined dream or goal • a deep sense of regret for goals not accomplished • a fear of humiliation among more successful colleagues • a desire to achieve a feeling of youthfulness

Sexuality Throughout the Lifecycle: Early Adulthood (approx 19-30) ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

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Case Vignette Maddie is a 19-year-old college student away from home for the first time. In high school she rarely went out, focusing instead on her grades. While she still wants to do well academically she is finding it difficult due to the number of opportunities she has to socialize. On her large college campus there are parties almost every night, and she has found herself involved in a number of casual hookups. Young adulthood is a time when many begin to embark on sexual relationships while outside the confines of their childhood homes and away from the watchful eyes of parents. In the United States and Europe, most adolescents initiate sexual intercourse in their 17th year (Finer & Philbin, 2013). Parental monitoring has been linked to delayed sexual initiation and safer sexual practices (DiClemente, Crosby, & Salazar, 2006).

In early adulthood, most romantic relationships involve a sexual component. Among young adults ages 18 to 23 who are in any form of romantic relationship, only about 6% are not having sex of some sort (Regnerus, 2007).

Traditional dating has declined on college campuses, hookups—casual sexual encounters often initiated at social events in which alcohol flows freely—have become a primary form of intimate interaction (Bogle, 2008). Hamilton and Armstrong (2009) conducted a longitudinal study in which they followed several young women throughout college. These authors point to conflict that some young women experience: while they have been socialized to prefer relationships, college norms make this much more difficult (although those that are too sexually active may be labeled in a derogatory way, a sexual double-standard). There is some evidence to suggest that casual sex may affect mood; one study showed that men who engage in casual sex show few depressive symptoms, on average, while women with a history of such liaisons report the highest levels of depression (Grello et al., 2006).

Another societal change for young adults involves relationship patterns (both sexual and affectional). The median for marriage has risen to 26 for women and 28 for men. Many emerging adults are “trying on” sexual relationships for several years before “settling down” (serial monogamy). Young adults regularly move into and out of intimate relationships, but most are short-lived (Regnerus, 2007). Another trend is “friends with benefits,” the practice of having sex in a nonromantic relationship with a friend (Bisson & Levine, 2009) and increased acceptance of pornography among young adults (Carroll et. al, 2008).

Sexuality Throughout the Lifecycle: Adulthood (approx 31-45)

Sexuality continues to develop into a person’s 30s and 40s. Patterns of serial monogamy are often replaced when people move into coupled relationships. These relationships are now characterized by increasing intimacy. Early writers on

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4 intimacy state that intimacy is conceptualized broadly as a process involving emotional and physical affection, closeness, cohesion, and sexuality (Waring, 1984). Intimacy results in partner closeness, friendship, and desire to share physical and emotional connections. Positive relationships with significant others in our adult years have been found to contribute to a state of wellbeing (Ryff & Singer, 2009).

Most adults identify themselves through their relationships with family— particularly spouses, children, and parents (Markus et al., 2004). Having stable intimate relationships has also been found to contribute to well being throughout adulthood (Vaillant, 2002).

The model of relational development (M.L. Knapp) explains how people come together (and come apart). While this model spans many types of relationships, it also elucidates the sexual coming together couples experience.

Coming together consists of five phases—initiating, experimentation, intensifying, integration, and bonding.

1. During initiating, first impressions are made; physical factors play a large role in this phase. This phase may be more superficial as people are trying to make a good first impression.

2. During experimentation, the two people attempt to find some common ground between each other’s lives, such as common interests and hobbies. People start to open up more and ask more personal questions as they get to know one another.

3. During the intensifying phase, people open themselves up fully in the hope of being accepted by the potential mate. During this phase, people may reveal things about themselves or others in order to test the trust level of potential partners.

4. The integration phase involves people merging their lives together and solidifying a relationship status.

5. Finally, during the bonding phase, people recognize a commitment to one another (traditionally through marriage, though many alternative forms of commitment exist) and the relationship lasts until death, breakup, or divorce.

Singles, Marrieds and Cohabitators

During adulthood, peoples choose to enter into intimate or sexual relationships or to remain uncoupled. The U.S. government defines marriage as a social union or contract between people that creates kinship. Marital relationships involve many

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5 components: legal, social, spiritual, economic and sexual. The institution of marriage predates recorded history. The term never married refers to adults who have never been married. Thirty percent of Americans have never been married — the largest percentage in the past 60 years, according to the latest U.S. Census (2010). Among those ages 25 to 29, the never-marrieds increased from 27% in 1986 to 47% in 2009. Given these statistics, it appears that most people in our society do eventually marry. Prior to making a marital commitment, many young adults engage in a pattern of serial monogamy, dating one exclusive partner, ending the relationship, then dating another. Males 30-44 report an average of 6-8 female sexual partners in their lifetime, while females 30-44 report an average of 4 male sexual partners in their lifetime. 56% of American men and 30% of American women have had 5 or more sex partners in their lifetime (Mosher, Chandra, & Jones, 2005).

There has been some change in dating patterns with the surge of Internet dating sites. This has vastly expanded the dating pool, which previously had included couples meeting through the introductions of family and friends and through institutions such as church and school. In early adulthood, it is common for couples to experiment with commitment at varying degrees, such as from an exclusive dating relationship to living together. Cohabitation refers to an arrangement whereby two people decide to live together on a long-term basis in an emotionally or sexually intimate relationship. From a sexuality perspective, it is interesting that cohabitation is a public declaration of a sexual relationship (Hyde & DeLamater, 2013). Cohabitation has become more common, and is sometimes an end to itself and not a precursor to marriage. About Cohabitation has often been characterized as a trial marriage and about 40% lead to marriage within two years and about 60% eventually culminate in marriage between the cohabiting partners.

Cohabitators do appear to engage in sexual behavior with more frequency than married persons. A sample of 7,000 adults found that married couples had sexual intercourse 8 to 11 times per month while those who lived together engaged in sexual intercourse 11 to 13 times per month (Call et al., 1995).

Sex and the Married Couple Case Vignette Kevin and Marie, ages 28 and 26 respectively, have been married for 7 years and are seeking marital counseling. In assessing their degree of intimacy, Dr. Janey found that a frequent source of conflict between the couple was what Kevin viewed as a rejection. The couple reported engaging in sexual intercourse approximately once a week; Kevin,

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6 however, felt that anything less that 2-3 times per week was insufficient and a cause of the other problems in the marriage. How much is “normal,” asks Kevin. Questions such as this are a frequent source of discussion in marital as well as individual counseling. Although it is difficult to identify a norm, it appears that engagement in sexual intercourse is mediated by age (see chart below). As would be expected, frequency declines as both men and women get older. The explanation for this is both biological, such as decrease in and poor health, and psychological, habituation to sex with the same partner. As with the case vignette, research has found that sexual inactivity has been associated with unhappiness in the marriage (Donnelly, 1993; Huston et al., 1996). Sexual dissatisfaction is associated with increased risk of divorce and relationship dissolution. (Karney, 1995).

A large-scale study by Donnelly (1993) analyzed marital sexuality. Donnelly interviewed 6,029 married people to determine which factors are related to sexually inactive marriages and if sexually inactive marriages are less happy and satisfying than those with sexual activity. Donnelly measured nineteen independent variables including: life satisfaction, religious fundamentalism, gender role traditionality, individualism, marital interaction variables, and marital happiness. She found that the lower the marital happiness and shared activity, the greater the chance of sexual inactivity and separation. Sexual inactivity was found to be associated with old age, the presence of small children, poor health, and in males, duration of marriage. Sexually inactive marriages are not happy, therefore, are not satisfying marriages.

Another study of married couples found age and marital satisfaction to be the two variables most associated with amount of sex. As couples age, they engage in sex less frequently with half of couples age 65-75 still engaging in sex, but less than one fourth of couples over 75 still sexually active. Across all ages couples that reported higher levels of marital satisfaction also reported higher frequencies of sex. (Call, 1995). The results of a large-scale study of married men and women is reported below. Kinsey Institute (NSSHB, 2010)

Percentage of Married Men Reporting Frequency of Vaginal Sex, N=2396 Age Group

18-24 25-29 30-39 40-49 50-59 60-69 70+

Not in past year 4.2 1.6 4.5 9.1 20.6 33.9 54.2

A few times per 12.5 9.3 15.6 16.2 25.0 21.2 24.2 year to monthly A few times per 30.0 36.4 32.5 24.1 31.8 20.5 63.2 month to weekly 2-3 times per week 26.0 27.1 39.0 25.3 18.8 38.6 0.0

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4 or more times per 10.0 6.3 6.5 11.5 4.7 2.3 0.0 week

Percentage of Married Women Reporting Frequency of Vaginal Sex, N=2393 Age Group

18-24 25-29 30-39 40-49 50-59 60-69 70+

Not in past year 11.8 3.5 6.5 8.1 22.0 37.0 53.5 A few times per 14.7 11.6 16.3 21.7 23.7 20.0 25.4 year to monthly A few times per 14.7 47.7 50.2 46.6 36.2 35.9 18.3 month to weekly 2-3 times per week 35.3 35.2 21.9 20.8 16.9 6.2 1.4 4 or more times per 23.5 2.0 5.1 2.7 1.1 0.0 1.4 week

Marital and Partnered Sexuality The chart above describes the frequency of vaginal sexual intercourse. According to the National Survey of Sexual Health and Behavior (NSSHB), there is much variability in the sexual repertoires of U.S. adults, with more than 40 combinations of sexual activity described at adults’ most recent sexual contact. It is rare that adult men and women engage in just one sex act when they have sex. While vaginal intercourse is still the most common sexual behavior reported by adults, many sexual events do not involve intercourse and include only partnered masturbation or oral sex (NSSHB, 2010). Determining what marital sexuality will be like has sometimes been described as a “mating dance,” or as the process of “negotiating sex.” Sexual Practices So what is “having sex”? In a recent study at The Kinsey Institute, nearly 45% of participants considered performing manual-genital stimulation to be “having sex,” 71% considered performing oral sex to be “sex,” 80.8% for anal-genital intercourse. Considerations of “sex” also varied depending on whether or not a condom was used, female or male orgasm, and if the respondent was performing or receiving the stimulation (NSSHB, 2010).

One sexual behavior that is often considered to be more taboo is anal intercourse. Part of the taboo concerns the perception that anal sex is generally a homosexual act. Anal sex commonly refers to the sex act involving insertion of the penis into the anus of a sexual partner. The term can also include other sexual acts involving the

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8 anus, analingus (anal–oral sex). Anal sex it is not rare, although it is reported by fewer women than other partnered sex behavior. Partnered women in the age groups between 18-49 are significantly more likely to report having anal sex (NSSHB, 2010).

Masturbation

While many people think that the trend to mature sexuality means that masturbation is unusual in adulthood, this is not the case. Many people masturbate, even while they are married and have access to partnered sex. This behavior is normal, but can sometimes be kept secret due to feelings of guilt. According to one study of the masturbation habits of men and women, nearly 85% of men and 45% of women who were living with a sexual partner reported masturbating by themselves in the past year (Laumann, Gagnon, Michael, Michaels, 1994). Masturbation, then, appears to be a healthy sexual outlet.

Within relationships, another pattern involves partnered or mutual masturbation. Mutual masturbation is a sexual act where two or more people stimulate themselves or one another sexually, usually with the hands. Across all age groups, partnered women are significantly more likely to report having engaged in partnered masturbation as compared to nonpartnered women (NSSHB, 2010).

Changes in Sexual Patterns Case Vignette

Sarah and John are presenting for counseling. John feels like his whole world his turned upside down following the birth of his son, who is now 8 months old. “Sarah and I used to be so close, and had a great sex life,” he says. “Since the baby has been born we’ve had sex a total of one time. She’s just not interested.” While Sarah recognizes John’s feelings, she responds that she is just “too tired” all the time and has had difficulty balancing the demands of work and a new baby. Within marriage and partnerships, there are changes in sexual patterns. There is often a decrease in the number of sexual encounters due to habituation ¾ couples becoming accustomed to one another sexually, which results in decreased interest in sex. Pregnancy

Another time in which there is much change in sexual patterns is following a pregnancy. These changes are at least initially motivated by physical parameters, but may also be psychological.

For married couples, the first child is often born within the first five years of marriage, which is also a period that has been shown to hold the highest risk for divorce (Bramlett & Mosher, 2001). Cowan and Cowan, who are some of the earliest

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9 authors to look at new parenthood and marital intimacy state: “we can conclude with some confidence that the transition to parenthood constitutes a period of stressful and sometimes maladaptive change for a significant proportion of new parents” (1995, p. 412). Several authors have looked at pregnancy and sexual function. Yenial and Petri (2014) conducted a comprehensive review on pregnancy, and sexual functioning. They found that sexual function decreases throughout pregnancy. The literature studied pointed to decreasing desire and orgasm, increasing pain and other problems in the first 3 months gradually improved within 6 months after delivery. This process is affected by many factors such as socio-cultural, age, parity, , depression, tiredness, sexual inactivity during the first trimester, postpartum body image, worries about getting pregnant again, and urinary tract infections. Serati et al. (2010) had similar conclusions about this time period, pointing to a significant decline during pregnancy, particularly in the third trimester and that persisted for 3-6 months following delivery. Breast-feeding, , and postpartum were reported as possible causes for the delay in resuming sexual intercourses after childbirth. After pregnancy, sexual contact is often delayed for several weeks or months, and may be difficult or painful for women. Injury to the perineum or are common reasons, as is vaginal dryness may occur following giving birth for about three months due to hormonal changes. Women who breast-feed are more likely to report painful sex and reduced , both due to hormonal changes such as a reduction in levels of . A water-soluble lubricant, such as K-Y jelly or AstroGlide, may be helpful in reducing dryness and discomfort. Although sexual activity other than intercourse is possible sooner, some women experience a prolonged loss of after giving birth. Although this is not uncommon, it is always advisable to consult with a physician.

Parenthood

While the articles described above looked primarily at the physiological aspects of sexual functioning in the and beyond and how the experience of parenthood affects sexuality and intimacy. While the changes in intimacy span a range of areas, overall scores of marital satisfaction in the postpartum period (up to 18 months following birth) suggest that this may be a time of more marital distance, including sexual distance (Gottman et al., 2002).

Many researchers have looked at early parenthood and marital satisfaction. Studies have shown declines in marital satisfaction immediately following birth (e.g., Gottman et al., 2002). Researchers have looks at a number of positive relationship factors including relationship-focused leisure time (needed for sex) and social support (Simpson et al., 2003).

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Doss (2009) suggests that a way to understand changes in post-birth relationship functioning is by using the conceptual framework of the Vulnerability-Stress- Adaptation (VSA) model (Karney & Bradbury, 1995). In this model, changes in relationship quality are understood to be a function of three interrelated constructs: enduring vulnerabilities, stressful events, and adaptive processes. Enduring vulnerabilities of the individual and the couple (e.g., limited education) increase chances of experiencing events as stressful and adapting poorly. Additionally, one could consider that while couples experience the same potentially stressful event (birth of their baby), the nature of that stressful event can vary substantially between couples. For example, the timing of the birth and the gender of the baby could alter the impact of the first baby on relationship functioning. Finally, couples have different levels of adaptive processes (e.g., communication, commitment) to help them cope with the stresses placed on their relationship functioning after birth. In looking at these factors we can better understand how some couples experience dissatisfaction and disruptions in relationship quality/sexual functioning while others may not.

Infidelity

Case Vignette Joslyn and Eric have been married for 8 years. Joslyn has recently noticed that Eric has become more distant. She was shocked to find that he had been exchanging text messages with a female co-worker. Although Eric denies that the relationship was in any way physical, Joslyn feels angry and hurt. She expresses uncertainty that she will be able to move past her feelings of betrayal.

Within intimate, partnered, and marital relationships, there is generally a belief in the exclusivity of the relationship, particularly sexual exclusivity. Infidelity is a breach of this expectation. Infidelity tests relationships and results in feelings of betrayal and mistrust. In our culture there is also a strong prohibition against infidelity, which includes both sexual breaches and emotional unfaithfulness. Smith (1994) surveyed Americans about infidelity and found that 90% of the general public agree that it is “always” or “almost always” wrong for a married person to engage in extramarital sex. The prohibition against infidelity also extends across cultures. Betzig (1989), for example, found Infidelity to be the most cited cause of divorce in over 150 cultures. Within the counseling relationship, many couples seeking counseling are presenting due to one partner’s unfaithfulness. How common is infidelity? Two studies of extramarital sex found similar statistics: approximately 20-25% of men and 10-15% of women engage in extramarital sex at least once during their marriage (Laumann, 1994; Wiederman, 1997). These studies did not include a sampling of cohabitating individuals. Treas and Giesen (2000) looked at infidelity among couples that are married or living together in a partnered relationship. The researchers found that 11% of adults who have ever been married or cohabited have been unfaithful to their partner (Treas & Giesen, 2000).

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The faces of infidelity There is some variability in what is considered infidelity. Certainly, sexual contact outside of a marital or partnered relationship is considered infidelity (except, of course, if the couple has the understanding that that is acceptable to both of them, such as in the case of an “open” marriage). There is less consensus, however, about other things that may be considered infidelity.

One such argument involves the idea of emotional infidelity ¾ emotional involvement with another person, which leads to the channeling of emotional resources, such as time and attention, to someone else. Another area that leads to disagreement is the use by one partner of pornography. This has become a particular concern in the age of the Internet. In a recent national study of Internet pornography, 14% of people reported having used a sexually explicit website ever, men more so than women. 25% of men reported visiting a pornographic site in the previous 30 days; 4% of women reported visiting pornographic sites in the same timeframe. (Buzzell, 2005). Additionally Mitchell et al. (2005) found that overuse, pornography, infidelity, and risky behaviors are among the most frequently treated Internet-related problems by mental health professionals. Although these areas are ones that merit further study, such statistics cannot be ignored.

Factors that contribute to infidelity Infidelity is influenced by many social and demographic factors. (Treas & Giesen, 2000) looked at these factors in a recent study. These researchers attempted to determine why some people are sexually exclusive while others have sex with someone besides their mate. Previous research had linked personal values, sexual opportunities, and quality of the marital relationship to extramartial sex. Treas and Giesen (2000) conducted a national survey of married and cohabitating couples. The researchers found that there is a higher likelihood of sexual infidelity among those with stronger sexual interests, more permissive sexual values, lower subjective satisfaction with their union, weaker network ties to partner, and greater sexual opportunities. Infidelity was also associated with having been part of a couple for a long time; having had a high number of prior sex partners and being male.

Midlife

Case Vignette Julia, age 53 and Carl, 56, have been married for 15 years. A second marriage for them both, and they have felt very close. While they had a robust sexual life in the early years of their marriage, they have noticed that neither one desires sex as much as they once

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12 did. Much of the reason concerns physiological changes. Julia is especially self- conscious about her higher weight, and Carl about his inability to achieve erection at Midlife is a time of change, sexual and otherwise. Midlife spans the ages of approximately 40-65, although there is great variability. At midlife, adults experience age-related changes based on many factors: primary aging (based on biological factors including physical and hormonal changes), and secondary factors (aging that occurs due to controllable factors, such as lack of physical exercise or poor diet.) In early adulthood (ages 20–40 physical abilities are at their peak. Aging speeds in midlife with multiple physical changes, cosmetic and otherwise. The skin becomes drier and wrinkles start to appear by the end of early adulthood.

The two hormones that most affect sexual physiology, estrogen and testosterone, tend to decrease during midlife, in both women and men. Women experience a gradual decline in fertility as they approach the onset of menopause—the end of the menstrual cycle—around 50 years old. Menopause results in the shifting hormone levels, resulting in a range of symptoms, such as mood swings, and less interest in sexual activity. Men, on the other hand, can continue to father children until late in life, many middle-aged men experience a decline in fertility and in frequency of orgasm. As these hormone levels decline, people commonly see symptoms such as decreased libido and changes in sexual response. But this is just the tip of the iceberg. At this time, there are also life changes, such as changes in roles relationships. Some examples include: becoming “empty nesters” after years of child-rearing, reaching career goals, transitioning to role of grandparent or caring for an aging parent. The loss of active parent role when children move out of the home is often accompanied by newfound gains in marital satisfaction and opportunities for exploring new interests, growth, and fulfillment (Ryff & Seltzer 1996).

Sexuality

According to Mitchell (2012) there are four primary components that influence sexuality in midlife. These are:

1. Self-perception. At midlife, it is common to experience changes in weight, fitness, appearance and mood causing people to feel less desirable and therefore less interested in sex. Some theorists also point to the "double standard of aging" causes women to seem less desirable as they lose their youthful appearance. For both men and women, anxiety about getting older is heightened in a society that places a premium on youth. This is also a time when adults are first diagnosed with chronic physical illnesses such as hypertension. 2. Gender role changes. Women at midlife often experience shifts in their priorities, beginning to focus on their own needs and self care, as well as creative endeavors. They often have a change in career and focus. Men are ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com

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more likely to slow down at work and are looking to balance their lives with more leisure. This impacts behaviors, including sexual behaviors, and can require negotiation of the relationship.

3. Sexual desire. Loss of libido is common in women as they go through perimenopause into menopause. Men may have a decreased libido as well, as their testosterone slowly wanes. 4. Sexual response: Women often describe slow arousal and difficulty with orgasm. A large proportion of middle-aged men experience erectile dysfunction. Sexual dysfunction can have physical causes but also may be related to health, lifestyle, and emotional well being.

Research on Sexuality at Midlife

What does the research say? Thomas et al. (2017) looked at sexuality among women in midlife, finding that there are positive and negative changes. The most common negative changes were decreased frequency of sex, low libido, vaginal dryness, and anorgasmia. Participants attributed negative changes to menopause, partner issues, and stress. Most participants responded to negative changes with adaptation, including changing sexual behavior and prioritizing different aspects of sex. Participants also reported positive changes, attributed to higher self-confidence, increased self-knowledge, and better communication skills with aging. Changes in midlife and older age, will be discussed in more detail later in this material.

Sexuality in Older Adults

Case Vignette Benjamin, age 74, and Jeanette, age 66, have been married for 47 years. They have weathered many challenges during this time, but are now really struggling. Their sex life, which had been mutually satisfying, has deteriorated due to Benjamin’s impotence. Although Jeanette has been patient, she is upset that her proud husband will not tell him doctor about the problem.

Sexuality occurs across the lifespan. Although there is some decline in the frequency of sexual contact as men and women age, many older men and women continue to be sexual (see the chart below). Many of the issues previously discussed, such as sexual communication issues and relational problems, apply to aging people. There are, however, specific, aging related issues that require some adaptation. While these do not apply to all older adults, it is helpful to understand some of the physical and psychological changes associated with aging.

Kinsey Institute Frequency of Sexual Intercourse

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Frequency Men 50-80+ Women 50-80+ Not in past year 46.4 58.0 A few times per year 17.8 13.5 2 or 3 times per week 24.6 20.3 A few times per month 10.2 6.8 4 or more times per week 0.9 1.4

The current population of older adults is one of the most highly educated and financially sound groups in history. It is also a very active group: nearly half of all Americans age 55 and over volunteered at least once in the past year. Even among those age 75 and older, 43 percent had volunteered at some point in the previous year. Older Americans no longer see retirement as an “endless vacation,” but increasingly as an active, engaged phase of life that includes work and public service (Fact Sheet on Aging, Experience Corps, n.d).

Although this is clearly a vibrant group of men and women, there are certain aspects of aging that can negatively affect sexual interest, activity and satisfaction. Among these factors are losses, changes in body image, changed living arrangements and physical changes associated with aging.

Psychological Changes Societal Prohibitions against Sexuality/Reactions to Aging

Ageism extends to our beliefs about sexuality. Older adults are often indirectly told that sexuality is for the young. Images in the media equate sexuality with youth. Sexual attractiveness, then, is often connected with the young. For women in particular there is a sexual double standard. Men are often thought to maintain their sexual activity, while older women are not. Sexually appealing women are depicted as young, and the importance of maintaining youth is supported by cosmetics that hide gray hair, wrinkles, etc. Women then are more prone to developing concerns about the physical aspects of aging, such as drooping breasts, weight gain, etc. There has been a rise in the number of late stage eating disorders, and these body image issues play a role in the increase. Body image, of course, affects sexuality (Crooks & Baur, 2000). Loss of a Partner Loss of a partner is a life crisis that many men and women will face over the course of their lifetime. Although people react to this crisis in many ways, some eschewing further relationships and some open to them. Women statistically have a longer life expectancy than men. More men than women, however, go on to remarry. One problem sometimes seen in this situation is the aptly named “widowers syndrome” in which a man can become sexually aroused by a new partner but cannot maintain

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15 an erection (Rossi, 1999) and which is often a result of survivor’s guilt. Women can experience the same problem.

Changes in Living Environment With increasing medical needs, many elderly people need to enter nursing homes or assisted living facilities. These environments often fail to address the sexual needs of older men and women. There may be restrictions on behavior or the inability to live with a spouse or partner. There are sometimes similar issues when an aging parent goes to live with a child. These issues need to be considered in making choices about living situations.

Physical Changes There are many physical changes associated with healthy aging, which are described below. Additionally there are illnesses that may limit a person's ability to relate sexually. Physical Changes in Women (Zeiss & Kasi-Godley, 2001)

• Reduced levels of hormones (estrogen, progesterone, androgen)

• Thinning of vaginal walls

• Decreased vaginal lubrication

• Changes in the labia, making penetration more difficult

• Reduction in vaginal contractions Physical Changes in Men (Zeiss & Kasi-Godley, 2001)

• Reduced levels of hormones (tester one)

• Decreased firmness during erections

• Reduction in amount of ejaculate

• Longer refractory period

• Need for more direct stimulation to support erection Research

Kalra et al. (2011) looked at sexuality in the elderly. They studied a group of participants to look at sexual function and activity in older age. The researchers found that in the group they studied 72% individuals below 60 were sexually active,

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16 while only 57% above 60 were active. Others had become completely abstinent at some time in their lives. Many people in the sample had chronic illnesses including diabetes, hypertension and arthritis. As high as 70% subjects perceived that their age negatively affected their sexuality, although expressed that the desire was still there. For those that reported lack of sexual activity, people reported various reasons for this including: men reported sexual inactivity because of lack of desire, ill health, or erectile dysfunction in their old age, whereas women reported sexual inactivity due to loss of partner. All of those surveyed agreed that they took significantly more time for sexual arousal compared to before. There was also a noted decrease in sexual satisfaction. One area that had generally not decreased (and in some cases increased) was intimacy). 48% subjects did not perceive any change in the areas of love and intimacy in their relationship over the years, while these areas had improved in 25% of the subjects’ lives.

Summary

Sexuality continues throughout the lifecycle, and physical and emotional intimacy are connected. It is important for mental heath professionals to be aware of the developmental changes that may affect adult sexuality, and to be nonjudgmental in approaching client needs with regard to enhanced sexuality in early, middle and later adulthood.

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