Aging and sexuality

Perimenopause means “around menopause” and refers to the natural transition to menopause, marking the end of the reproductive years. Perimenopause is also called the menopausal transition.

Perimenopause starts at different ages for different people. Signs of approaching menopause, like menstrual irregularity or hot flashes, can start in our mid-forties but some people may notice signs as early as their thirties.

The level of estrogen in our bodies goes up and down unevenly during perimenopause. Our menstrual cycles may lengthen or shorten, and we may begin having menstrual cycles in which we don’t ovulate. The change in estrogen may also cause menopause-like symptoms such as hot flashes, sleep problems, mood disturbances, and vaginal dryness. Treatments are available to help ease these symptoms, so talk to your health care provider. After twelve consecutive months without a menstrual period, you have officially entered menopause!

Perimenopause and menopause are major life events. We deserve access to health information and support as we navigate and manage the changes they bring. Perimenopause and menopause can change our everyday life, how we relate to others, our sexuality, our body, our levels of energy, our mood, our mental health, and general wellbeing. Perimenopause and menopause’s mood swings and emotional impacts can be very difficult. Good mental health care during this time is important. Unfortunately, we rarely talk openly about menopause, making it hard for us to feel validated. This is especially true for who experience perimenopause and menopause.

Beyond the changes in our bodies, menopause can impact sexual function. Changes in estrogen and progesterone during menopause can cause vaginal dryness and discomfort, possible pain during intercourse because of skin becoming thinner and more brittle, recurrent urinary tract infections, loss of bladder control, and a decrease in libido. Sexual arousal and desire may also change; however, if you have satisfactory sexual intimacy before menopause, this will likely continue. Addressing sexual function issues to continue enjoying a happy healthy sex life is not out of reach.

Medical support such as hormone replacement therapy (HRT) is an option and can help reduce symptoms—some people may even experience an increase in sexual libido on HRT. You can also seek support from health professionals like naturopathic doctors, physiotherapists, pelvic floor specialists, and sex coaches. When bringing up your need or desire for HRT with your health care team, it is important to include sexual side effects in the conversation to ensure that any interventions also address sexual health issues.

Incontinence, the loss of bladder control or leaking of urine, is more common as we grow older. This is especially true for those of us who have experienced pregnancy and birth earlier in life. Extra pressure on the bladder during sex can cause us to lose urine and this can lower our desire to have sex. Incontinence can usually be treated. Changing sexual positions or emptying the bladder before and after sex can help. Consulting a pelvic floor physiotherapist can also help with incontinence. Click here to read more about incontinence.

Erectile challenges become more common as we age. Erectile dysfunction is the loss of ability to have and keep an erection. This means it can take longer to have an erection and it may not be as firm or as large as it used to be. It also means the loss of erection after orgasm can happen more quickly or it can take longer before another erection is possible. Erectile dysfunction is not a problem if it happens every now and then but talk to your doctor if it occurs often.

That’s especially important because erectile disfunction can also be a sign of underlying health issues and help your health care provider identify them.

Dealing with erectile challenges can make us feel self-conscious, anxious, depressed, or angry, which in turn can impact sexual function. Different medical interventions and medications can help increase blood flow to the penis (it is important to know about contraindication, something health care providers can help identify). Many people find therapy to be helpful, particularly when erectile dysfunction is caused by performance anxiety. Open communication is key—we can adapt the sex we’re having and find different ways to remain intimate even when we’re experiencing erectile dysfunction.

Talk to your health care providers for support and discuss ways to make sex easier and more comfortable. Remember: accessing health care for the changes we go through as we age, including sexual changes, is a common and normal experience.

Click here for some tips on how to improve the relationship you have with your health care team.

Cancer can develop at any age but is much more common in older people. Almost 9 in 10 cancer cases are in people aged 50 and over, with about a third in people aged over 75. A cancer diagnosis and treatment can impact our overall health and wellbeing. It changes how we relate to others and our bodies and we may have to navigate new disabilities or challenges. Many may also experience sexual side effects. For instance, gynecological, colorectal, and anal cancers may make penetrative sex more difficult or impossible, while treatment such as chemotherapy can impact lubrication, libido, sexual interest, and energy levels. Breast cancer, which may result in mastectomy, as well as other cancers involving physical changes, can impact how we relate to our bodies. Maintaining a good quality of life means paying attention to our sexual health wellbeing, so receiving the support of a health care team that considers sexual health as an important part of our health when exploring treatment options can play a major role in a holistic and affirming approach to care.

Getting it on: some tips

Many of the changes that can take place in and around our genitals as we age are caused by a lack of blood flow, muscle loss, and hormonal changes. Encouraging maximum blood flow to our bits, ideally on a regular basis, is an excellent way to keep tissue healthy and maintain an interest in sexual play. Here’s what you can do:

1. Moisturize and/or massage your genitals daily with coconut oil, silicone lube, or a water-based lube.
2. Do Kegel exercises (flexing and tightening of the pelvic floor muscles using exercises). A pelvic floor specialist can help you figure out how best to strengthen these muscles.
3. Use vibration and/or suction to increase blood flow and sensation. This can be great for any erectile challenges as well.
4. Encourage extended foreplay and touch before penetration.
5. Do penetrative exercises with a dilator or smooth dildo to help keep vaginal or anal tissue elastic and pliable.
6. Place a warm washcloth on the genitals before sexual play. This will bring blood to the surface and relax the tissue. A bath would work in a similar way but can be too drying for some.
7. Use erotica, exploration, experimentation, and creative fantasizing. Variety can help keep things interesting.

When we talk about aging and sexual health, it is important to talk about the unique barriers faced by two-spirit, lesbian, gay, bisexual, trans, and queer seniors when it comes to accessing housing, health care, long-term care, and other needed services.

Many health and social service providers intentionally avoid conversations around sexuality and gender identity because they believe that a patient’s sexuality or gender identity has “nothing to do with” the care they deliver. Other health care providers might assume that all patients are heterosexual and cisgender, risking misunderstanding, discrimination, erasure, and mistreatment.

Aging 2SLGTBQ+ folks face significant barriers to receiving health care, including health care providers who are uninformed about their sexuality or gender identity or actively hostile towards 2SLGBTQ+ folks. This means that many people avoid accessing health care services (including palliative care services) because they anticipate stigma or discrimination or don’t believe support services would meet their needs. Concerns that loved ones will not be recognized as next of kin is also a major barrier to health care.

Aging 2SLGTBQ+ folks are often invisible in services, policies, and research. For example, policies within hospitals may limit visitation to only biological family or married spouses, leaving out chosen family, unmarried partners, or anyone who doesn’t “fit the bill.” They end up having to fight for their right to visit their loved ones at time of hospitalization.

Studies on 2SLGTBQ+ aging outline three specific generations of aging 2SLGTBQ+ people:

• The Invisible Generation: those who came of age during the Great Depression and World Word II and who were largely left out of public discourse.
• The Silent Generation: those who came of age during a period of great persecution of people who challenged sexual and gender norms. Their identities were seen as threats to national security and many aspects of sexual expression were criminalized and/or classified as psychiatric disorders.
• The Pride Generation: those who came of age during a time of significant social change, kicked off by the Stonewall riots and civil rights movement. 2SLGTBQ+ folks became more visible in the public and political spheres, beginning the process of decriminalization of their gender and sexuality. This generation is also marked by the AIDS pandemic.

While there is a steadily growing number of social support services for 2SLGBTQ+ youth and adults, 2SLGTBQ+ seniors have fewer spaces to gather. For those who require long-term care, few options exist for affirming living. This is exacerbated by the fact that 2SLGBTQ+ seniors are more likely to avoid accessing health care until later in life, to experience financial difficulties, and therefore may access fewer social services.

It is a priority that any health care and housing services that serve older adults ensure that their environments and policies create welcoming spaces for all.

The short answer is yes. Age doesn’t protect us from STIs, which are very common for those of us who are sexually active. STI rates among older adults are increasing. Between 2002 and 2011, chlamydia rates in people over 50 tripled, syphilis rates increased five times, and gonorrhea rates doubled. In 2011, people over 50 represented 18.2% of new positive HIV tests in Canada. Baby boomers are considered high risk for which they may have contracted before blood donations was actively being tested. Researchers estimate that up to 70% of people born between 1956 and 1975 who have Hepatitis C are unaware of their infection status.

Many infections are asymptomatic or, if symptoms are present, they can mimic the normal signs of aging and can easily be overlooked. Age-related changes like decreased vaginal lubrication and thinning of vaginal walls and anal tissue can also increase the chances of getting an STI. The lack of sexual health information where older adults gather or live is a contributing factor in the rising rates of infections and delays to diagnose and treat. Incorporating routine testing is important at all ages, even if you don’t experience any symptoms of an STI.

Sexuality at end of life In the terminal stages of illness and at the end of life, sexuality is often not considered important by health care providers. The need or ability to participate in sexual activity may fade in the terminal stages of illness but the need for touch, intimacy, and relationships doesn’t necessarily vanish. People may in fact suffer from the absence of loving and intimate touch in the final months, weeks, or days of life.

It is often assumed that when life nears its end, people and couples are not concerned about sexuality. This attitude is a result of little information and visibility on sex, death, and how they intersect; however loving relationships, intimacy, and sexual contact are important even during terminal illness. Sexuality can be a key component of holistic care and overall quality of life and should be prioritized by caregivers and health care providers to improve the wellbeing of dying people. Sexuality can also provide closeness and closure at end of life.

Physical relationships may become difficult after receiving a terminal diagnosis, often because of how illness impacts the body. People can experience changes in their appearance and physical and emotional pain that affect both libido and sexual functioning. Relationships can also change as partners take on caregiving roles and tasks, which can impact intimacy and expressions of sexuality. This often happens at a time when individuals wish to strengthen relationships with the ones they love, so it’s crucial that health care providers and caregivers help facilitate expressions of intimacy and sexuality among patients and their loved ones.

One study explored how sexuality was experienced by palliative care patients. In this study, respondents identified sexuality as “emotional closeness” and noted that closeness frequently meant activities other than sex. Sexuality is diverse and includes different forms of sexual expression. In the end, sexuality is whatever it means to the patient. Caregivers should allow the person they are caring for to define sexuality on their own terms and practice it in ways that make sense for them.

Here’s what it looks like for a health care team to address the sexual needs of patients:

• Giving patients and their loved ones explicit permission to touch each other even at advanced stages of an illness.
• Becoming fierce advocates of patient privacy. In health care settings, this may mean advocating for single-occupancy rooms. When people receive care at home, they can be moved to common living spaces for the sake of easier access to care. This can make being intimate with a partner difficult. People can be encouraged to close doors or curtains when private time is desired.
• Giving permission to partners to lie with their loved ones in bed, even in palliative care. In most situations, kissing, stroking, massaging, and holding a terminally ill patient is unlikely to cause physical harm and can facilitate relaxation and decrease pain.
• Encouraging loved ones to participate in their partner’s care routine can be a way to encourage touch and closeness.
• Normalizing and validating sexual health issues as normal and legitimate health concerns during terminal illness or end of life.
• Initiating conversations to provide an opportunity for patients to discuss their needs and desires.
• Avoiding showing discomfort when discussing sexuality. People can sense this discomfort and will shy away from talking about their sexuality-related concerns.
• Treating individuals as people—not as their disease or illness. This includes sexuality as a key component of their holistic wellness.
• Ensuring the use of inclusive terms when discussing family, loved ones and romantic partners. This can be as simple as using the word “partner” or “partners” instead of presuming heterosexuality, monogamy, or assuming that individuals are married.

A health care team dedicated to a holistic approach to end of life care can help devise specific strategies to continue sexual activities. Supporting patients and couples to see themselves as sexual in the face of terminal illness is an important first step. Offering the patient/couple the opportunity to discuss sexual concerns or needs validates their feelings and may normalize their experience.

The PLISSIT Model is used in sex therapy and can be useful for introducing sexuality and sexual health discussions within clinical care. There are four key components of this model:

1. Permission: show a willingness to discuss sexuality related topics and include an open-ended invitation to further the conversation (e.g., “those in similar situations have expressed concerns about intimacy and sex. What concerns are you having?”).
2. Limited Information: provide brief education to patients and partners regarding common sexual side effects associated with the illness and its treatment.
3. Specific Suggestions: give concrete suggestions to patients on how they may cope with effects of the illness. This is important whether or not individuals are in relationships and may involve discussion on how sexual pleasure was achieved prior to the diagnosis.
4. Intensive Therapy: provide referrals to a sex therapist or relationship counselor if it is required or helpful for the individual.

If you are currently experiencing a terminal or life-altering illness or injury, here are some useful questions to ask yourself when advocating for health care that acknowledges your right to be intimate:

• How important is sexual intimacy to you? How important is it to your partner(s)?
• What helps you feel close and connected with your partner(s)?
• What changes have you noticed in your sexual functioning?
• How has this illness or injury impacted your sexual relationship with your partner(s)?
• What kind of supports could help you maintain physical closeness with your partner(s)?

You have a right to pleasure and closeness at this important moment in your life.