interested in sex?

Transcription

interested in sex?

Sexuality in later life:
The older couple – interested in
sex?
Ms Claudine Domoney MA MBBChir MRCOG
Consultant Obstetrician and Gynaecologist
Chelsea and Westminster Hospital, London
Chair of the Institute of Psychosexual Medicine
Life expectancy UK 2004
C Domoney - BGS Aut 09
WHO 1978
Sexual health is a state of physical,
emotional, mental and social wellbeing in relation to sexuality;
it is not merely the absence of
disease, dysfunction or infirmity.
Tuesday, Oct 06 2009
Pam, 68, said: "We're more experienced,
more mature and more confident and we're
able to talk about what we want which
makes us better lovers."
Training of health care professionals
involved in care of older people

Practice nurses
GP
Continence advisors
Physiotherapy
OT
Nurses
Physicians
Surgeons
Medical students
Masters and Johnson
model of human sexuality
Intimacy based model of
female sexuality Basson et al
May not need/have spontaneous drive
orgasm cf -men
C or
Domoney
BGS
Aut 09
Male sexual dysfunction

Desire disorders
Erectile dysfunction
Male orgasmic disorders
Ejaculatory disorders
Premature ejaculation

Female sexual dysfunction

Desire disorders
Arousal disorders
Orgasmic disorders
Pain
Non coital pain
disorders
Definitions

What is normal?
What is abnormal?
Normal frequency and satisfaction rates
Age related factors
Dyspareunia and sexual dysfunction rates
What cultural differences/variables are
recognised?
Relationships
National Sexual Attitudes and Lifestyles Survey 2001

unmarried, cohabiting
couples sex x3 /wk
1st year of marriage
x3/ 2wks

ages 33-45 x1/wk

ages 45-55 x1/month
Statistics

US study age 18-59 •Ï difficulties with age
43% women FSD
•Ð activity with age
31% men
• 32 % > 60
Laumann et al JAMA 1999
• 56 % married women
•Married women > unmarried
•Increased satisfaction with
relationship
•Benefit for genital aging
Sexual activity and age

Variation amongst European
women country by country

N = 601 age 45-60
Frequency intercourse only
significantly different factor
BMI

Beckman et al BMJ 2008

Dennerstein & Lehert Menopause 2004

Australian cohort age 45-55

FSD 42% Î 88% from early
to late menopause

Revised study incorporating
personal distress ↓ rate

Hayes, Dennerstein 2005, 2008

Higher satisfaction
Less sexual dysfunction
More +ve attitude
2000-1 cf 1971-2

Dennerstein 2003

70 year old Swedish popns
Improvement in sexual
experiences over 30 year
period
57% vs 40% men happy
52% vs 35% women
Sexual debut <20

52% to 77% men
19% to 64% women
Sexuality and older people

Research findings -cessation more likely to be
male driven – consistent for 40 years
Last 30 years? ×ejaculatory problems and
dissatisfaction cf ED (but phosphodiesterase
inhibitors)
Earlier sexual debut linked with more +ve
attitudes
Satisfaction increasing in women overall
BMJ Editorial Kleinplatz 2008
Importance of attribute to quality of life
(Score 4-5 on 5 pt scale) in AARP Modern
Maturity Sexuality Survey 2004
56% feel satisfying sexual relationship important (62% in 1999 survey)
Less important to women and older groups
Impotence in males in AARP Modern
31% completely or moderately impotent (increase from 26% in 1999)
Up to 60% in 70+
Sexual attitudes in AARP Modern
• ¾ too much
emphasis on
sex
• 6/10 critical
part of
relationship
Sexual behaviour: AARP Modern
Sexual drive: AARP Modern
Significant difference between men and women not having
C Domoney - BGS
any sexual feelings > 70 yrs
Aut 09
Sexual activity by partner status: AARP
Modern Maturity Sexuality Survey 2004
Women without a partner significantlyCfewer
sexual activities
Domoney
- BGS Aut
09
Other data from AARP Modern

Reduction in sexual
activity

With medical condition
On prescription medication
Not having physically active
life

Frequency of orgasm

2/3 men
1/3 women
Younger > older
4% men same sex
partner, 1% women
2/3 satisfied with sex life
14% used medications to
treat sexual problem
(incl hormones)
Sex information: AARP Modern
Differences by race/ethnicity
Modern Maturity Sexuality Survey 2004
Satisfaction with sex life
European perception of sexuality around the
menopause –Nappi & Nijland 2008

Have you experienced a reduced
sex drive more so in the last few
years than any other time of life?
1805 women age 50 -60
1488 with partner
Telephone survey
Not more so
recently
19%
36% reduced sex drive
21% vaginal pain / dryness/
discomfort
>50% sample reported sexual
contact at least 4x/month
Don’t know
5%
Never
experienced
44%
Recently
experienced
32%
Most likely
Switzerland
61%
Most likely
UK 47%

Differences between countries
Germany
54%
France 40%
Netherlands 40%
European perception of sexuality around the
menopause –Nappi & Nijland 2008
Have you experienced vaginal pain/
dryness during sex more so in
recent years?
Not more so
recently
12%
Recently
experienced
20%
Don’t know
4%
Most likely
Italy
/Switzerland/
France 69%
Never experienced
64%
Most likely
UK 31%
Worldwide survey of attitudes to sex and
problems in men and women.
Nicolosi et al Urology 2004
Men and women reporting intercourse
frequency of more than once a week
Worldwide survey of attitudes to sex and
problems in men and women.
Nicolosi et al Urology 2004
Women and men with at least one problem, by world region
Sex

Increases length of life
Greater well being
Better relationships in general
Better immune system
Normal effects of ageing
on the female

Reduced arousal
Reduced sensitivity
Reduced orgasmic potential
Mucosal changes

Dry, delicate, less elastic, painful/sensitive
Changes in skin, hair, body
Urogenital atrophy
NR

Age 69
Met 1st partner for 20 years
Never anticipated problem
Penetration not possible
‘Vagina the shape of a pencil’

6 health professionals later.....
Vaginal oestrogens
Normal effects of ageing
on the male

Reduced arousal
Decreased sensitivity
Reduced ejaculatory volume
Increased resolution phase
Decreased penile angle
Medical history

General health and well being
Approach to ageing
Medical disorders incl mental health
Surgery
Pelvic floor disorders
Drug history
Alcohol/ smoking
Medications impacting on sexuality

Antidepressants and mood stabilisers
Antihypertensives
Cardiovascular drugs
Statins
Digoxin

Hormones or antihormones
H2 blockers
Anticonvulsants

Contribution of the
diminution of the
senses

Sight
Speech
Smell
Touch
Hearing
Why do we not find those who
want or need further help?

Fear of health professionals

Can of worms

No ‘specialist’ to refer to

Patient expectations
What to ask?

Are you in a sexual relationship?

Do you have a partner?

Are you sexually active?

Do you have any difficulties?

Are they a problem for you?

Do you have pain during sex?
If you don’t ask....
You won’t get
Physician enquiry increases patient
reporting of sexual dysfunction

3% spontaneously
report
16% report after
direct questioning

Screening for sexual
problems

Bachmann et al 1989
effectiveness of 3 simple
screening questions
compared to detailed
interview by sex therapist
Three simple questions
yielded same results as the
detailed therapist interview
Plouffe L, Am J Obstet Gynecol

3 non-intrusive questions
addressing:
Desire, Discomfort,
Satisfaction
Physicians, patients and sexual
problems

Pts experiences with
physicians management

52% not ready to talk
about problem
76% not thorough exam
85% no diagnosis
87% no FU
Berman et al Fertil Steril 2003

Hindrances for patient

Too embarrassed
Not enough time
Would have if Dr initiated
Physician seemed too
rushed
Help

Dr initiates
Dr comfortable
Dr Kind/inderstanding
Dr seemed concerned
Nusbaum et al Maturitas 2004

Mid 60s
Treated for ovarian
cancer
Libido returned with a
vengeance
Concern regarding
recurrence
TH
Never make assumptions
about what sexual
feelings mean to an
individual
Influences on sexual behaviour

Abnormality

Feelings about body

Failure of arousal, fear

Understanding of condition
and its treatment

Feelings about genitals and
abnormalities

Ignorance

Operations

Hormones

Effect of pathology

Effect of treatment

Psychosexual problems
exacerbating physical
symptoms
Previous experiences
Key events
Understanding of ‘hidden
agenda’
Partners feelings and problems
SP

Age 74
Multiple pelvic floor operations
?motivated to continue with sexual activity
Brought husband
Sat looking like old man
We’re too old, its silly, its ridiculous at our age
Towards the end of the consultation starts to
get a glint in his eye – ‘ a naughty little boy
again’
Sex

A psychosomatic activity
Involves body and mind

Psychosexual medicine

= mind-body doctoring
Involves genital examination as ‘moment of
truth’
Use of the physical examination as a therapeutic
event
AV Age 64

c/o OAB
Interest in
questionnaire
Loss of sensation
Relationship
difficulties
Lack of control
Ultimate defence
Discussion lubricants
and E2
NSF for Older People 2007

listen to older people
respect their dignity and privacy
recognise individual differences and specific needs
including cultural and religious differences
enable older people to make informed choices, involving
them in all decisions about their needs and care
provide co-ordinated and integrated service responses
involve and support carers whenever necessary.
Same sex relationships

Difficulty in expressing
sexuality to carers
Little provision in
residential care
Direct effects of disease or illness

Neurological

Genital

Mobility

Pain
Safer sex
Sexually transmitted diseases
in older people

STIs in > 45 yr olds doubled in last 10 years
>50yrs 2000-2005

Warts most common
X2 chlamydia
X3 HSV
HIV 0.7% to 2.2%
Increase in new partners in older age group
Less understanding of safe sex
Less/no need for contraception
Opportunities

Tourism
Internet
Speed dating
Cruises
Residential care

>500 000 people over 65 in residential
care
Long term needs

Privacy
Dignity

‘Expression of sexuality’

Catheters

Female and male catheters

Consideration of suprapubic

Penile injuries possible

Positioning
Erectile dysfunction

1 in 10
2.3 million men in the UK

× with age

Causes physical and psychological

Management of ED

Phosphodiesterase 5 inhibitors
Hormones - testosterone
Penile rings
Penile scrotal rings
Vacuum devices
Injectable prostaglandins
Intracavernous
Intraurethral

Vacuum constriction device in use
Initiation of vacuum
Pump removed, ring in place
Constriction ring for use alone
Penile rings
Penile scrotal rings
Three part inflatable prosthesis
Three part prosthesis in-situ
BT Age 69

Vault prolapse
Effect on sexual life
Sacrospinous fixation
Shortened vagina postop
Further procedure
Use of dilators
Collusion of both partners
Female sexual dysfunction

Psychosexual treatment
Hormones

Systemic hormone replacement

Topical hormones
Vaginal remoisturiser

Oestrogen/ testosterone
(Replens MD –prescribable)
Lubricants
Sylk
Non water based

Hormones

Topical oestrogen
Oestrogen
replacement

Cyclical- non bleed
Testosterone
replacement
Sexual aids
Lubricants
Vaginal trainers/dilators
PW Age 66

Recurrent prolapse
Large rectocoele
Healthy sex life preoperatively
Postop

Infection
Mesh erosion
Treatment with antibiotics and mesh removal
Given dilators & vaginal oestrogen
Rejected further psychosexual input

–use natural dilator
Elder abuse

Concern for vulnerable adults
May have reduced ability to express abuse
Carers
Low threshold of suspicion
Conclusions

It is important for men and women of all
ages to feel they can discuss sexual issues
with their health care providers
There may have been changes in the
general population over time that increase
the importance of sexuality
Training is available for all!