Felipe Hurtado Murillo1, 2, 3 , Ascensión Bellver-Pérez4, 2 and Woet L. Gianotten5
(1)
Sexual and Reproductive Health Unit “Fuente San Luis”, Health Department, Valencia Doctor Peset, Valencia, Spain
(2)
Department of Personality, Assessment and Psychological Treatment, University of Valencia, Valencia, Spain
(3)
The National Distance Education University (UNED), Madrid, Spain
(4)
Sexual and Reproductive Health Unit “Doctor Peset”, Health Department, Valencia Doctor Peset, Valencia, Spain
(5)
Physical Rehabilitation Sexology, Rehabilitation Centre De Trappenberg, Huizen, The Netherlands
Felipe Hurtado Murillo (Corresponding author)
Email: hurtado_fel@gva.es
Email: felipehurtadomurillo@gmail.com
Ascensión Bellver-Pérez
Email: bellver_asc@gva.es
32.1 Introduction
Cancer as a special topic in the senior group is not much discussed in the professional literature, and the same goes for sexuality in old age. That apparent accumulation of taboos does not offer justice to the reality of many aging patients and their partners. There are several arguments to pay proper attention to sexuality in the group of aging cancer patients.
· In the current era, people live much longer. Over the last 50 years, the life expectancy in Western Europe increased with more than 10 years to over 80. In those five decades, the percentage of the European population over age 65 increased from 10.9 to 19.2 %.
One of the consequences of higher age is a higher cancer incidence.
· The aged population is also changing [1, 2]. There is a clear difference between generation and age. Many groups in the current aging population in Western Europe have witnessed and were part of the sexual revolution and the diminishing role of religion. They grew up with contraception and sexual openness. Furthermore, over the last decades, PDE5-inhibitors, vibrators, and the erotic possibilities of Internet became available and accepted by many [3]. Obviously, many of the new aged generations will claim a good sexual quality of life.
· Nowadays, part of the aged population is also blessed with a good physical condition. Their healthy lifestyle resulted in good cognitive function and good sexual function till high age.
· Another part of the aged is that they are less lucky with their physical outcome and they suffer from various age-related diseases and medical interventions that impair their sexual capacities. However, since many of them grew up with comparable above-mentioned social changes and conditions, they will have the same desire for a good sexual quality of life.
· We dare to predict that the developments that took place in the Western European countries will happen as well in many other places.
We will start this chapter with some general information on sexuality in the aged and address separately three aspects with major influence on sexuality in the aged: (1) physiological changes; (2) consequences of diseases, comorbidity, and medical interventions; (3) some typical partner aspects of aging. After that we will look at some of the specific changes in sexuality and intimacy after cancer and its treatment. Finally, we will give recommendations on how to deal with this area.
32.2 Sexuality in the Aged
Definitions and classifications on age and aging tend to be artificial and do not really represent general differences. Societies tend to look at chronological age and for instance define old age as the life ranging from age 65 to death. Such a social construct varies from one society to another and from one era to another. It ignores “functional and biological age,” in health care much more relevant. Another classification is to divide into:
|
Midlife |
40–54 years |
|
Third phase |
55–74 years |
|
Fourth phase |
75-onward |
In this chapter, we will mainly look at the upper range of the third and the fourth phases. Except for the physiological changes of the menopause, there are no clear markers that define age, and the same goes for sexuality. We usually say that sexuality reaches its maximum expression between 25 and 40 years and then declines steadily in both sexes, although for different reasons. One of the reasons for this diminishing sexual frequency appears to be the longer duration of relationships. On the other hand, when aged persons start a new relationship, some of them have again a very active sexual life (and they can fall madly in love even at age 80+). Several studies have shown that sexual interest and activity can last well into the eighth decade of life.
In an American study, 57 % of people aged 65–74 years remained sexually active as well as 26 % of people aged 74–84 years [4].
In Sweden, they looked at the sexual life of 70-year-old people in 1971, and they did that again in another group of 70-year-old people in 2000. Comparing those data is not an age effect but a generation effect. The differences were tremendous! From 1971 to 2000, the proportion of 70-year olds reporting sexual intercourse increased among all groups: married men from 52 to 68 %, married women from 38 to 56 %, unmarried men from 30 to 54 %, and unmarried women from 0.8 to 12 %. An intercourse frequency of ≥1×/week increased in men from 10 to 31 % and in women from 9 to 26 %. Men and women from later birth cohorts reported higher satisfaction with sexuality, fewer sexual dysfunctions, and more positive attitudes to sexuality in later life than those from earlier birth cohorts. In the early group, 41 % of 70-year-old women indicated never to have an orgasm, whereas 30 years later that had gone back to 6 % [1]. A larger proportion of men (57 % vs. 40 %) and women (52 % vs. 35 %) reported very happy relationships in the 2000-cohort compared with those in the 1971-cohort.
Sexual activity was related to positive attitude toward sexuality, sexual debut before age 20, having a very happy relationship, having a physically and mentally healthy partner, self-reported good global health, interviewer-rated good mental health, being married/cohabiting, satisfaction with sleep, and drinking alcohol more than three times a week [2].
The most relevant factors for continued sexual activity in older age are:
· Active prior sexual history
· A good state of physical, mental, and sociocultural health
· The availability of a receptive sex partner without functional limitations
Sexuality is not only about frequency. When comparing (not at an individual level, but at a group level), one of the common relative differences between men and women is that women tend to focus more on intimacy, whereas men tend to focus more on performance. In younger age, the male scripts are predominant, but in higher age the female scripts tend to become more important. That fits nicely with the diminished male stamina and with the reduced erectile capacity. This is probably one of the explanations for the apparent high frequency of oral sex in seniors.
At the same time, we should be aware that even in the upper age groups, there is a lot of diversity. Some seniors have only gentle, soft sex (“vanilla sex”), whereas others can be very horny and some even enjoy kinky sex.
Another aspect of the sexual multidimensionality in the aged is the relative more frequent spiritual connection with intimacy and sexuality [5] (Table 32.1).
Table 32.1
Factors affecting sexual activity in old age (independent of cancer)
|
1. The influence of health with various diseases in this stage of life. Cardiovascular disease, diabetes, lipid disorders, rheumatic diseases, Parkinson’s, and beginning dementia. |
|
Certain surgeries such as prostatectomy or hysterectomy. Various medications such as antihypertensives, lipid lowering drugs, psychotropic drugs, analgesics, or anti-inflammatory drugs with their potential sexual side effects. |
|
2. Lifestyles that accelerate processes of physiological aging and loss of energy. Consumption of alcohol, tobacco or drugs; poor diet, sedentary lifestyle, poor hygiene, insomnia, or fatigue. |
|
3. Psychosocial, cultural, and religious factors. Especially in the generations with absent or repressive sexual education, with the traditional obligation for procreation and marriage, denying homosexual orientation and enforcing conventional gender roles. |
|
4. The previous sexual history. A history rich in sexual activity and satisfaction during youth and adulthood is associated with a better sex life in old age. |
|
5. The availability of partner. Many seniors lose their partner. Establishing a new relationship at a higher age can be difficult, especially for women. |
32.3 Physiological Changes of Aging in Women
Even when dealing only with the upper range of the third and the fourth phases of the woman’s life, one cannot get around the reality and the influence of the menopause. Apart from being the end of fertility, the menopause is a phase of transition from a life with regular monthly hormonal changes to a life without cycles. This transition period can be accompanied by a wide variety of complaints (ranging from nearly none to very much). Complaints like hot flashes, poor sleep, irregular loss of blood, and irritability can start or aggravate disturbances of sexuality and intimacy but also the psychological perception of some women about not being fertile any more.
At the end of this transition period, the ovaries have stopped producing hormones; so, the menopause is also the beginning of a life without estrogen and with only half of the androgens (since the adrenal glands took care for the other half, and they continue to supply androgens).
From now, estrogen deprivation can develop because many female organs and tissues need that hormone. Such a physiological estrogen deprivation is a gradual process. It usually takes years to develop osteoporosis, skin changes, and atrophy of vagina and vulva.
In women of higher age, the next changes can be found:
· More atrophy of the vagina with higher pH and more sensitivity for vaginal infections.
· The vagina can become shorter with less elasticity and thinner mucous membranes.
· The genital labia become thinner, and lower elasticity can narrow the entrance of the vulva.
· Longer time and more stimulation are needed to reach the same amount of lubrication.
· Less subcutaneous fat in the external genitalia, causing an increase in postcoital cystitis.
· Orgasm is shorter in duration with fewer contractions. The potency to orgasm does not seem to diminish.
· Less pubic hair and a decrease in female scent.
· Whereas in part of the women, the lower androgen levels cause less sexual desire, in others the absence of estrogen causes lower SHBG levels giving higher bioavailable testosterone levels that can lead to more sexual desire (and sometimes signs of hirsutism).
· The skin can lose elasticity and gloss with increased dryness.
· The muscles lose some tone and strength.
· The distribution of subcutaneous fat changes with more deposits in abdomen and waist and usually also with weight gain.
All these menopausal changes create new conditions (and new challenges) for sexual activity, depending on the woman’s coping mechanism and her adaptations in lifestyle.
“Use it or lose it” seems a rather relevant adage at least for muscles and for sexual function.
32.4 Physiological Changes of Aging in Men
Men have no clear transition phase, and the biological changes toward aging are not as spectacular and brusque as in menopause. The endocrine levels lower more gradually, and so does the physical decline. From around age 40, there is an average 1 % annual decrease in total T (testosterone)-levels in natural decline (or 0.04 nmol/L) [6].
Many men have a lifestyle that influences the hypothalamic-pituitary-gonadal axis causing increased loss of Leydig cells and a much faster decline in total T levels. The gradual increase of SHBG is another reason for lower levels of bioavailable T.
All aging men end up somewhere in the wide range between slightly lower T-levels and sheer hypogonadism. The latter goes with decreased muscle mass and muscle power, decreased sense of well-being, increased abdominal fat, changed insulin resistance, and a worse lipid profile. Lower T is also accompanied by more depressive symptoms and cognitive decline.
Lower T is also responsible for decreased sexual function with lower arousability, less sexual desire, less spontaneous erections, and less sex-related erections.
The normal age-related changes in the healthy male contain a decline in β-adrenergic and cholinergic receptors and an increase in α-adrenergic activity. That interferes with the penile smooth muscle relaxation causing reduced erectile capacity. Elastic fibers are replaced by connective tissue, causing less penile expansibility. Erections will be less rigid, and the penis is also less sensitive (although erection becomes also more dependent on direct penoscrotal stimulation).
It will take more time to reach maximum erection, and for part of the men, it will take more time to reach orgasm (diminishing premature ejaculation for them). Orgasm is shorter in duration with fewer contractions and less expulsion force. After orgasm, there is faster detumescence, and the refractory period will be longer (and can even take days).
32.5 Influence of Diseases, Comorbidity, and Medical Interventions
Advancing age is associated with increasing vulnerability to multiple comorbidities – such as diabetes, hypertension, arthritis, and vascular and heart diseases – and other age-related conditions including dementia, incontinence, and balance disorders [7]. In the Western world, half of the people in the 55–65 age group have at least one chronic disease, and that rises to 75 % above age 75. Modern medical care will keep many people alive surviving such chronic conditions. Whereas the physiological changes of aging usually do not really damage sexual function, many of those diseases of aging and the accompanying medical interventions can impair sexuality.
Obviously, the complexity increases with more diseases and its company of a wide range of medication (“polypharmacy”) adding numerous reasons for directly disturbing sexual function and indirectly disturbing sexual identity (by influencing outer appearance).
Sexual dysfunction in seniors does not always mean a sexual problem, as the accompanying bother decreases with age. For instance, a substantial amount of aging European men does not consider their erectile dysfunction as a problem. This apparently is in contrast with American data (usually with a higher incidence and no mentioning of bother).
32.6 Typical Partner Aspects of Aging
In the above-mentioned Swedish research, sexual activity was positively related to having a very happy relationship and having a physically and mentally healthy partner, whereas having an older partner was related to less sexual activity [2].
Not having a partner is for many a serious problem. There are several ways to lose the sexual relationship with the partner.
Every relationship carries the reality of losing one’s partner. For the aged, that usually is because of death. In the European Union, the life expectancy at birth is 83 years for women and 77.2 years for men. On top of this 5.8-year difference, most women have been partnered to a man who is 2–3 years older. That will statistically create eight annual cohorts of heterosexual women without a partner. What that means for sexuality and intimacy will strongly depend on her generation and the culture she lives in and on her own process of sexual individuation.
In case of dementia, the partner is not really lost, but one gradually loses contact. This “virtual widowhood” can have very complex consequences for sexuality and intimacy.
A third relevant reason to stop partner sexuality is when the partner (or the couple) is not able to adapt to the consequences of disease or sexual aging. The challenge of erectile difficulties or dyspareunia is for some couples an introduction to renegotiate intimacy. For others, their traditional concept of sexuality and its nearly inevitable script of vaginal intercourse can preclude new developments and lead to complete loss of intimacy [8].
When again single, many seniors will miss their familiar amount of intimacy or sexuality. Especially after many decades of monogamy, it will be rather confusing and challenging to restart a relationship (frequently also evoking resistance by the children).
In spite of the physical needs, it can be also very daring to re-enter the sexual arena with wrinkles, less firm breasts, some urinary incontinence, easy flatulence, and a less firm erection.
32.7 Relevant Aspects of Cancer in Senior Adults
In geriatric oncology, the aspect of comorbidity is very relevant [7]. Comorbidities are an independent indicator of survival. Accounting for comorbidities is an essential step in deciding for a treatment modality, especially with the knowledge that in this age group more people die with cancer than from cancer. Besides, older people usually care more about quality of life rather than longevity (“adding life to their years instead of adding years to their life”).
That creates a collision of two realities. On the one hand, many treatment modalities in cancer can cause extensive disturbances in sexuality and intimacy. On the other hand, few seniors will bring up the sexual topic in the discussion, although for a substantial part of them, sexual expression and intimacy form a vital element of their quality of life. This means that for good care the professionals should proactively include sexuality and intimacy in the process of shared decision making.
Prostate cancer is an example of a different approach in the aged population. With less expected remaining years of life, active surveillance (“watchful waiting”) can be an appropriate treatment in low-risk, low-volume prostate cancer. Although this strategy causes uncertainty, sexuality is not so much disturbed.
Regarding the consequences of treatment modalities, it seems that both the surgical and radiotherapy risks in aging patients are mainly related to coexisting morbidities, rather than to age by itself [7]. That seems different for chemotherapy. Every aspect of drug pharmacokinetics is potentially affected in older patients, and this explains in part why they have an increased range of chemotherapy toxicity [7].
One of them is the “chemobrain phenomenon.” This chemotherapy-induced impairment of memory, executive function, or information processing speed is found in patients with breast cancer. Studies on older patients suggest that the impact could be more pronounced in older patients with preexisting troubles [9].
Cognitive decline tends to diminish the quality of life and the compliance to treatment. It will also impact the autonomy of patient and partner with negative (and sometimes also some positive) consequences for intimacy.
With sexual function being influenced by a multitude of biological, psychological, relational, and cultural factors, it is difficult to make conclusions on the cause of disturbances. Younger age has been shown to have better sexual recovery in women after gynaecological cancer, and in men after nerve-sparing radical prostatectomy [10].
32.8 Some Recommendations on Dealing with Sexuality in Older People with Cancer
Part of the aged patients with disturbed sexuality can sufficiently deal with that by themselves. However, another part cannot handle that situation, resulting in sadness, loss of connection, and less quality of life. That psychological burden need not and maybe should not stay unresolved. In the exhausting journey of cancer treatment and recovery (or farewell), every additional fragment of intimacy and sexuality can mean physical, emotional, or relational benefit.
Potentially, that is a very relevant aspect of care. Whereas this on the one hand will be very valuable for part of the patients and part of the partners, we know on the other hand that very few of them will broach this topic by themselves. We consider it professional responsibility to figure out if this patient, this partner, or this couple needs additional attention in the area of intimacy and sexuality. Since a person’s appearance does not indicate how important that area is, we have to proactively ask. That goes even for the single patient and even for the very old patients and partners.
Elderly patients can be challenging, not only because of factors like additional comorbidities, polypharmacy, slower movement, and impaired hearing, but sometimes also because of traditional shyness around sexuality. Dealing with them will take more time. The other side is the benefit we can obtain from talking with the aged. Many can teach us how to handle our own aging.
Primary key elements in contact with the aged are respect and dignity. When dealing with their disturbances in sexuality and intimacy, recognition is an important element, and then proper information (explanation/education).
There is a broad range of strategies for disturbed sexuality, and most of them can be used as well in the aging population. Here, we will only mention some elements that apply more explicitly to the elderly.
For Men
· When diminished erection → direct penile stimulation increases the likelihood of effect
· When diminished erection → a lubricant (nonwater-based) will increase the chance for effect
· When no more erection → many men still can have an orgasm with sufficient arousal and stimulation
· When low desire → consider the possibility of hypogonadism and (when allowed) appropriate testosteron replacement
· When orgasm is difficult → many aged men can learn to enjoy the other parts of sexual play without stress and tension
For Women
· When too dry → try increasing arousal before intercourse
· If dryness then continues → consider lubricants
· In case of dyspareunia → consider possibility of hypoestrogenism and (when allowed) appropriate replacement
· In case of low desire → consider possibility of hypoandrogenism and (when allowed) appropriate androgen/testosteron replacement
For Men and Women
· In case of fatigue → change timing of sexual contact to the morning. That matches also with the highest testosterone level (both in male and in female).
· When intercourse is no more possible → consider restructuring the scenario (“renegotiate intimacy”) [8].
· Do not forget the topic of sexuality in the palliative phase.
· Do not forget the importance of the topic after loss of the partner.
Even without any erection, lubrication, or orgasm, physical intimacy is for many couples a major source of connection and happiness. Since part of our cancer patients apparently forget that, it is wise to remind them to invest in that area.
In case of real complex sexual disturbances, high-quality expertise can be needed, but for the majority of sexual troubles, the professional does not have to be an expert in this area. With compassion and understanding, one can achieve a lot in this aspect of care.
Not addressing the topic of sexuality in patients with cancer is a form of bad care.
Addressing sexuality, but not in senior patients is a form of age discrimination.
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