3. Learning Objectives
1. Participants will be able to describe the unique
challenges (both individual and systemic) older
adults face in pursuing sexual intimacy.
2. Participants will be able to identify commonly used
interventions for sexual problems in later life as well
as appropriate therapeutic accommodations.
3. Participants will be able to identify appropriate
assessment measures and techniques in assessing
sexual dysfunction in older adults.
4. Agenda
1. Why late life sexuality?
2. Barriers to youthful sex in aging adults
3. Appropriate accommodations
4. Assessment of sexual problems
5. Intervention for sexual problems
6. Call to action!
7. Resources
5. Why late life sexuality?
Aging population –
upcoming cohorts
Majority of OAs report sex
as important to life,
relationships, and
successful aging
Associated with a myriad of
physical and mental health
benefits
6. • Many older adults engage in a
myriad of sexual behaviors
across the lifespan
• Frequency of sex for the
sexually active similar across
adult age groups, more decline
begins at age 74
• In oldest ages, typical behaviors
include hugging, sexual
touching, and kissing
Older Adults are Sexual Beings
AARP, 2010; Herbenick et al., 2010; Holden et al., 2014
7. Physical Barriers to Youthful Sex
• Vaginal dryness
• Thinning of the vaginal wall
• Erectile dysfunction
• Pain/Disability
• Decreased sensation
• Potential for injury
• General health problems
• Medication side effects
8. Social/Societal Barriers to Youthful Sex
• Tend to effect women more than men:
• Women are less likely to be partnered than men (AOA, 2015)
45% of women over 65 are partnered vs.
70% of men over 65
• Women without a partner are less likely to be sexually active
4% of unpartnered women are sexually active vs.
22% of unpartnered men
• Available partners diminish over time
• Stigma and discrimination
• Fear of rejection due to physical changes/attractiveness
• Traditional gender roles
9. Therapeutic Accommodations
• Communication
• Well-articulated, strong voice (hearing loss)
• Face/body language visible (hearing loss)
• Slow-paced (processing speed)
• Provide written aids in large print (memory changes)
• Word choice (cohort effects)
• Intervention/Assessment Pacing
• Extend sessions/treatment duration (multiple causes)
• Limit new material (memory changes)
• Repetition (memory changes)
• Intervention/Assessment Design
• Break up large subjects/material (memory/processing speed)
• Involve caregivers/partners (multiple causes)
• Avoid abstraction – use concrete language/examples (reasoning)
• Incorporate the social/physical environment (social context)
10. Assessment Tools:
1. Structured clinical interview (Syme et al., 2015)
2. European Male Ageing Study Sexual Functioning
Questionnaire (EMAS-SFQ; O’Connor et al., 2008)
3. McCoy Female Sexuality Questionnaire (MFSQ; McCoy,
2000)
4. Sexual Beliefs and Information Questionnaire (SBIQ-R;
Adams et al., 1996)
5. Aging Sexual Knowledge and Attitudes Scale (ASKAS;
White, 1982)
11. Clinical Interview Outline (Syme et al., 2015)
I. Introduction and Presenting Issues/Goals
A. Nature of the sexual issue and basic goals/hopes for treatment
II. Sexual Functioning/Current Symptoms
A. Desire
B. Difficulties with sexual thoughts, fantasies, interest, urges
C. Excitement/Arousal
D. Orgasm
E. Sexual Penetration/Pain
III. Sexual Well-Being Status
A. Biopsychosocial aspects of sexual wellness
IV. Sexual history
A. Baseline sexual functioning—focus on when going well
B. Onset of sexual concerns
C. Coping Strategies
V. Current Sexuality (Behaviors, Relationships, Attitudes, and Beliefs)
A. Sexual scripts (typical sexual encounter)
B. Relationship with primary partner
C. Sexual Orientation and Gender Identity
D. Beliefs/Attitudes/Values
VI. Medical and Mental Health Contributions/History
12. Assessment Considerations
Integrated care settings (brief, flexible tools)
o 5 A’s approach
o Arizona Sexual Experience Scale
(ASEX; McGahuey et al., 2000)
Long-term care setting
o Functional assessment
o Cognitive assessment
o Consent capacity
Syme, forthcoming; Hillman, 2016; Licthenberg, 2014
13. Intervention Strategies:
First Steps
• Psychoeducation
• Reduce Stigma
• Cognitive Restructuring
• Motivational Interviewing
• Referral to Physician/Urologist
• Assessment
• Pharmaceutical/Surgical Intervention
• PDE5 Inhibitors, Penile vacuums, Injectable
vasoactive drugs, penile implants, etc.
• OTC sexual products
14. Intervention Strategies:
Second-Order Treatments
• Consider referral to sex therapist
• Cognitive Behavioral Interventions
• Start/Stop
• Sensate Focus
• Stimulus Control
• Cognitive Restructuring
• Communication Skills
• Mindfulness-based Interventions
• Sensual Mindfulness (adjunctive to sensate focus)
• Values-based Discussions
15. What to do Next!
• Ask about sexual health/satisfaction regardless of age,
gender, orientation, religious preference, etc. (>25% seek
treatment; Laumann et al., 2009)
• Are you satisfied with your sexual life?
• If say yes, then encourage future discussion should problems emerge.
• If say no, then… “Well, I’m sorry to hear that. Is this an area you would
like help with either from me or another provider today?”
• Consider your own views of sexual health and sexuality
across the lifespan. Beware counter-transference!
• Advocate for patient’s sexual health and satisfaction
whether in team meetings, individually, or with families.
16. ABA/APA Assessment of Older Adults with Diminished Capacity: APA/ABA
http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-
handbook.pdf
Administration on Aging. (2015). Profile of older Americans. Washington, DC: United
States Department of Health and Human Services.
Brick et al. (2009). Older, wiser, and sexually smarter: 30 sex ed lessons for adults only.
Morristown, NJ: Planned Parenthood of Greater Northern New Jersey.
Laumann et al. (2009) A population-based survey of sexual activity, sexual problems
and associated help-seeking behavior patterns in mature adults in the United States of
America. International Journal of Impotence Research, 21, 171-178.
Syme, M.L., Cordes, C.C., Cameron, R.P., & Mona, L.R. (2015). Sexual health and well-
being in the context of aging. In. P.A. Lichtenberg, B. Carpenter (Eds.), APA Handbook
of Clinical Geropsychology. Washington DC: American Psychological Association.
References
17. Principles and Practices of Sex
Therapy – Fifth Edition (2014)
Sexuality and Aging (2012)
APA Resource Guide for Aging and
Human Sexuality
http://www.apa.org/pi/aging/resources/guides/sexuality.aspx
National Institute on Aging (NIH)
https://www.nia.nih.gov/
Resources
Older adult data says (Lindau et al., 2007):
Majority engaged in intimate relationships
Frequency of sexual activity for sexually active similar to adults 18-59 years of age
Frequency of activity decreased with age only minimally up to age 74
NSHAP:
Sexual expression does decline in older age, compared to younger years, but those who are sexually active have sex fairly often and this remains stable through age 75, with only modest decreases in frequency over age 75.
Full sample: WOMEN – 61.6% of 57-64, 39.5% of 65-74, 16.7% of 75-85; MEN – 837% 57-64, 67% of 65-74, 38.5% of 75-85
Partnered sample: WOMEN – 80.7% of 57-64, 62.8% of 65-74, 41.4% of 75-85; MEN – 90.5% of 57-64, 74.7% of 65-74, 54.2% of 75-85
Sexual expression – behaviors primarily vaginal intercourse with foreplay behaviors (kissing, caressing, etc.), and this stays fairly constant across ages
In oldest ages, sexual activity is primarily sexual touching, hugging, and kissing
Possibly due to cohort differences and patterns established in younger years
Importance of sex tends to decline with age, with older adult women more often reporting sex not being at all important across older age groups (women 57-64 at 24%, men at 6.2%)
Prevalence data from large, cross-sectional studies suggest OAs are engaging in sexual activity and experiencing associated benefits
NSHAP: 73% of 57-64 were engaging in sexual activity over the past year. Of those active ages 65-74, 65% of men and women reported frequent activity (2-3 times per month)
GSSAB: Sexual well-being related to happiness in OAs, over and above health and physical activity
Continue to report problems with sexual lives
GSSAB: 43% of older adult women reported at least one problem, including lack of interest, difficulty achieving orgasm, sexual pain, partners sexual health, or lack of sexual partner, body image and sexual self-esteem issues
OA men tend to experience erectile dysfunction (ED), reduced desire, prolonged plateau and refractory phases, and also sexual self-esteem issues, though less often reported and/or measured than females
5A’s
For the provider working in integrated primary care or other medical settings, the clinical assessment will likely be limited to a 15-20 minute encounter that aims to simultaneously initiate an intervention. The 5 A’s (Assess, Advise, Agree, Assist, and Arrange) is a leading assessment and intervention approach to chronic health conditions in primary care (Hunter, Goodie, Oordt, & Dobmeyer, 2009). It allows providers to address sexual health needs in a focused manner, as they assess beliefs, behaviors, and knowledge regarding sexual expression, advise patients by providing specific information and suggestions, agree on collaboratively-set clinical goals, assist patients to identify strategies to address their concerns, and arrange necessary follow up with specialty services as indicated (Hunter et al., 2009).
ASEX
Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.
5A’s
For the provider working in integrated primary care or other medical settings, the clinical assessment will likely be limited to a 15-20 minute encounter that aims to simultaneously initiate an intervention. The 5 A’s (Assess, Advise, Agree, Assist, and Arrange) is a leading assessment and intervention approach to chronic health conditions in primary care (Hunter, Goodie, Oordt, & Dobmeyer, 2009). It allows providers to address sexual health needs in a focused manner, as they assess beliefs, behaviors, and knowledge regarding sexual expression, advise patients by providing specific information and suggestions, agree on collaboratively-set clinical goals, assist patients to identify strategies to address their concerns, and arrange necessary follow up with specialty services as indicated (Hunter et al., 2009).
ASEX
Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.
5A’s
For the provider working in integrated primary care or other medical settings, the clinical assessment will likely be limited to a 15-20 minute encounter that aims to simultaneously initiate an intervention. The 5 A’s (Assess, Advise, Agree, Assist, and Arrange) is a leading assessment and intervention approach to chronic health conditions in primary care (Hunter, Goodie, Oordt, & Dobmeyer, 2009). It allows providers to address sexual health needs in a focused manner, as they assess beliefs, behaviors, and knowledge regarding sexual expression, advise patients by providing specific information and suggestions, agree on collaboratively-set clinical goals, assist patients to identify strategies to address their concerns, and arrange necessary follow up with specialty services as indicated (Hunter et al., 2009).
ASEX
Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.
5A’s
For the provider working in integrated primary care or other medical settings, the clinical assessment will likely be limited to a 15-20 minute encounter that aims to simultaneously initiate an intervention. The 5 A’s (Assess, Advise, Agree, Assist, and Arrange) is a leading assessment and intervention approach to chronic health conditions in primary care (Hunter, Goodie, Oordt, & Dobmeyer, 2009). It allows providers to address sexual health needs in a focused manner, as they assess beliefs, behaviors, and knowledge regarding sexual expression, advise patients by providing specific information and suggestions, agree on collaboratively-set clinical goals, assist patients to identify strategies to address their concerns, and arrange necessary follow up with specialty services as indicated (Hunter et al., 2009).
ASEX
Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.
5A’s
For the provider working in integrated primary care or other medical settings, the clinical assessment will likely be limited to a 15-20 minute encounter that aims to simultaneously initiate an intervention. The 5 A’s (Assess, Advise, Agree, Assist, and Arrange) is a leading assessment and intervention approach to chronic health conditions in primary care (Hunter, Goodie, Oordt, & Dobmeyer, 2009). It allows providers to address sexual health needs in a focused manner, as they assess beliefs, behaviors, and knowledge regarding sexual expression, advise patients by providing specific information and suggestions, agree on collaboratively-set clinical goals, assist patients to identify strategies to address their concerns, and arrange necessary follow up with specialty services as indicated (Hunter et al., 2009).
ASEX
Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.
5A’s
For the provider working in integrated primary care or other medical settings, the clinical assessment will likely be limited to a 15-20 minute encounter that aims to simultaneously initiate an intervention. The 5 A’s (Assess, Advise, Agree, Assist, and Arrange) is a leading assessment and intervention approach to chronic health conditions in primary care (Hunter, Goodie, Oordt, & Dobmeyer, 2009). It allows providers to address sexual health needs in a focused manner, as they assess beliefs, behaviors, and knowledge regarding sexual expression, advise patients by providing specific information and suggestions, agree on collaboratively-set clinical goals, assist patients to identify strategies to address their concerns, and arrange necessary follow up with specialty services as indicated (Hunter et al., 2009).
ASEX
Although sexual dysfunction is common in psychiatric patients, quantification of sexual dysfunction is limited by the paucity of validated, user-friendly scales. In order to address this problem, the authors have developed the Arizona Sexual Experiences Scale (ASEX), a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm. Possible total scores range from 5 to 30, with the higher scores indicating more sexual dysfunction. This study assesses the internal consistency, test-retest reliability, and convergent and discriminant validity of the ASEX.
