First comprehensive national survey charts sexual behavior among older adults

Data from the University of Chicago's National Social Life, Health and Aging Project (NSHAP), presented in the August 23, 2007, issue of the New England Journal of Medicine, showed that many men and women remain sexually active -- participating in vaginal intercourse, oral sex and masturbation -- well into their 70s and 80s.

The survey also found that sexual activity was closely tied to overall health, which was even more important than age. As health declined steadily after the early 70s, so did the prevalence of sexual activity, particularly for women. Among those who remained sexually active, nearly half reported at least one sexual problem, such as lack of desire (43% of women), vaginal dryness (39% of women) or erectile dysfunction (37% of men).

"We found that older adults remain interested and engage in sex, yet many experience bothersome sexual problems that can compromise both health and relationships," said Stacy Tesser Lindau, MD, assistant professor of obstetrics and gynecology and of medicine-geriatrics at the University of Chicago and lead author of the study.

With the first baby boomers turning 60, older adults make up the fastest growing segment of the US population. Yet the "lack of reliable information about how sexual activity and function might change with age and illness, combined with taboos around discussing sex in later life, contributes to worry or even shame for many older adults," she added.

"I am especially happy that we now have in hand reliable and comprehensive information on sexual function and activity among older adults based on a scientifically drawn representative sample of Americans 57 years of age and older," said co-author Edward Laumann, PhD, the George Herbert Mead Distinguished Service Professor in Sociology and co-director of the 1992 National Health and Social Life Survey, which surveyed persons aged 18 to 59.

"Social relationships are known to contribute to health and well-being in older men and women," says Richard Suzman, PhD, director of the Social and Behavioral Research Program at the National Institute on Aging, which primarily funded the study. "This pioneering research gives us valuable insight into intimate social relationships, providing data clinicians may now draw upon to open better informed conversations with patients about sexuality and health."

Many medical conditions and treatments can interfere with sexuality. American men spend more than a billion dollars each year on medications to improve sexual function. Despite such frequent problems, few older men (38%) and even fewer women (22%) had discussed sex with a physician since age 50, the researchers found. Men were more likely to do so, perhaps because effective drugs are available. Nearly 1 in 7 men (14%) reported taking medication to improve sexual function.

The survey documented another significant gender difference. While 78 percent of men ages 75 to 85 have a spouse or other intimate relationship, only 40 percent of women that age do, a consequence of the age disparity of relationships coupled with women's greater longevity.

"Sexuality is an important part of a healthy and engaged life at older ages for both women and men," said co-author Linda Waite, PhD, the Lucy Flower Professor in Urban Sociology at the University of Chicago and Director of the Center for Aging at NORC. For the vast majority of men, aging is a partnered experience, "but women's sexuality," Waite said, "is more often affected by the death or poor health of their spouse."

NSHAP, funded by the National Institutes of Health, was created to discover how social relationships, especially intimate relationships, influence health as people age. Between July 2005 and March 2006, the researchers interviewed 3,005 people ages 57 to 85 in their homes. They asked about social and marital history, sexual activity and function, and physical and mental health.

While there have been other surveys focused on the older population, "they have typically been based on convenience samples with low completion rates or clinical samples with unknown biases in representing the population at large," Laumann said. Such surveys typically over- or under-estimate the prevalence of sexual problems. "NSHAP provides us with a much more reliable guide to strengths and weaknesses of sexual health in the older population of the United States."

Another new element of NSHAP is the collection of physiological specimens such as spots of blood, saliva and vaginal swabs. In follow-up studies, the researchers will use these specimens to extract various "biomarkers." These will provide evidence about hormone levels, prevalence of diseases such as heart disease or diabetes, and the frequency of human papillomavirus, a sexually transmitted disease.

The NSHAP team also gathered data on how older adults perceive the world of social relationships, assessing participants' sense of touch, taste and smell as well as vision and hearing.

Despite the personal nature of many of the questions, study participants were very forthcoming, as expected from prior clinical and research experience with older adults. Seventy-five percent of those approached agreed to participate. Overall, only 2 to 7 percent declined to answer direct questions about sexual activities or problems. (Fourteen percent did not answer questions about masturbation on a self-administered questionnaire.) "Participants were more likely to refuse questions about income than they were about sex," Lindau said.

Many of those who were sexually active found ways to remain active, despite worsening health. The proportion of sexually active couples that engage in oral sex, for example, hovered at around 50 percent for those under 75. More than half of men and a quarter of women, whether they had a sexual partner or not, acknowledged masturbating.

"Although sexuality has long been thought to deteriorate inevitably with age, we found that health is a more important indicator for many aspects of sexuality than is age alone," Lindau said. "This suggests that older adults with medical problems, or those considering treatment that might affect sexuality, should be counseled based on health status rather than just their age."

The most common reported reason for sexual inactivity among individuals with a spousal or other intimate relationship for men (55%) and women (64%) was the male partner's physical health. Women, especially those who were not in a current relationship, were more likely than men to report lack of interest in sex.

Despite the unprecedented shift in the age of the population, the public, physicians and policymakers lack information on sexual behavior at older ages and on how sexual activities and problems change with age and illness.

"We hope our findings improve public health by countering harmful stereotypes and allowing older individuals to view their experience relative to others," Lindau said. "It may comfort people to know that they are not alone in enjoying sexual activity as they age or in experiencing sexual problems, some of which could be alleviated with medical attention."

This report, according to the authors, provides the first such reference for clinical decision making. It "should improve patient education and counseling," they conclude, and help identify "health related and potentially treatable sexual problems."

The National Health, Social Life and Aging Project is supported by the National Institutes of Health, including the National Institute on Aging, the Office of Research on Women's Health, the Office of AIDS Research, and the Office of Behavioral and Social Sciences Research. NSHAP is also supported by the National Opinion Research Center, whose staff was responsible for the data collection.

Additional authors of the study include Philip Schumm and Colm A. O'Muircheartaigh of the University of Chicago and Wendy Levinson of the University of Toronto.