Aging and Male Sexuality.

Aging and Male Sexuality. By Raul C. Schiavi. New York: Cambridge University Press, 1999, 253 pages. Paper, $44.95.

Reviewed by Kurt A. DeBord, Lincoln University, Department of Social and Behavioral Sciences, Jefferson City, MO 65102-0029.

Myths, misconceptions, and negative stereotypes abound in the area of aging and male sexuality. The book under review attempts to dispel researchers and mental health practitioners of such notions by educating them about recent research and theoretical developments in the physiological and psychosocial aspects of older men's sexual functioning. In composing this book, Raul Schiavi drew upon his extensive clinical work as a psychiatrist and his notable research experience to generate penetrating social commentary, sharp critiques of the extant literature, and enlightening discussions of medical information that could benefit those even remotely involved in the health of our aging population. These outstanding features of the book will be discussed first, followed by a brief consideration of the book's weaker points.

The specific target audience of the book includes psychiatrists, gerontologists, psychologists, sex researchers, and those involved in the clinical aspects of sexuality and aging. Schiavi successfully accomplished his goal of addressing this audience by keeping his discourse relatively free of technical terminology, aside from those chapters where the focus was primarily medical. In fact, Schiavi so sensitively and adeptly weaves his prose that many lay readers would be well served by a thorough examination of his volume. Unfortunately, however, the book is not presented at a level that would make it readily accessible as a patient education resource for the general public. This is unfortunate because the information is timely and practical.

The book begins with sharp social commentary, elucidation of concepts, and critiques of research methods typically used in the field. These three elements are consistently drawn throughout the text in a way that reminds readers of the distinctiveness and relative newness of this field and its place in an overall social context. For instance, within the first paragraph of chapter one readers are challenged to recognize that in recent times the aged frequently have been viewed as a "problematic social group" (p. 1). Schiavi continues his assault on negatively-biased misconceptions of the aged by summarizing research indicating that older individuals do not differ from younger ones on measures of self-efficacy, control, or life satisfaction. He also introduces and elaborates thoroughly upon "successful aging" (p. 5), a concept that, at a minimum, should nudge many mental health care professionals from their traditional perspectives.

Schiavi continues to demonstrate his expertise in the first chapter by offering insightful critiques of the common experimental methods in research on male sexuality and aging. He calls attention to the problem of ignored cohort effects in cross-sectional designs in nearly every instance where such a study is reviewed throughout the book. He implores readers to avoid assuming that the aged are a homogeneous group in light of the fact that many reviewed studies emphasize group mean differences. And he repeatedly urges caution in making generalizations based on studies of older men's sexuality that utilize convenience samples. Such studies typically ignore the importance of participants' medical conditions or their conditions of privilege that drew them to participate in the study in the first place. These illustrations of methodological critiques are characteristic not only of the first chapter, but also of the entire book.

Schiavi consistently reminds readers of the limitations of current research in almost every chapter. This priority is one of the book's greatest strengths. As this book will undoubtedly serve as a resource of reviewed research in this area, it is important that Schiavi draws attention to the following: the limits of retrospective reports, the lack of norms on assessment measures, the lack of racial representation in most samples, the confounding variables ignored by prominent researchers, and the gaps in areas of empirical work. Not only will clinicians benefit from these reminders, but future investigators, too, will be able to improve the quality of study being conducted in this area. Schiavi is well aware of the fruits of his labor, and uses a portion of the book to describe a recent study of his that avoids many of the pitfalls of previous research.

Schiavi's reputation as a sex researcher precedes him, but his skilled analyses of this research area serves to add credibility to his voice as a commentator on social and theoretical issues relevant to men and sexuality. This commentary is, indeed, another one of the book's great strengths. Schiavi points out problems in the treatment of the institutionalized aged, in the cultural construction of the male midlife crisis, and in the prevalent emphasis on sexual performance over sexual satisfaction. But perhaps most importantly, Schiavi criticizes the all-too-common error made by patients and caregivers alike, the assumption that the physiological and psychosocial factors in the etiology of sexual disorders are regularly distinct and noninteractive. This theme is reiterated throughout the book and eventually emerges as a focal point of it.

The natural evolution of this theme is aided by Schiavi's familiarity and fluency with the language of health psychology. His clinical experience is evident in his description of the significance of positive affect, cognitive appraisals, self-esteem, and coping strategies in dealing with male sexual disorders. It is truly remarkable to witness the author's ability to transition from medical topics to psychosocial ones. For example, he moves effortlessly from a discussion of the technical effects of psychoactive medications on sexual performance in one chapter to a discussion of the importance of assimilative coping in the next. Schiavi clearly values the medical model, but he is never one to underestimate the complexity and power of the psychosocial variables in the onset and treatment of sexual disorders in the male aged.

In addition to the numerous great strengths of this book, there are problems, although, in comparison, they are minor. Most of these problems involve readership issues, case studies, and omissions. First, given the target audience, there will cetainly be many readers who get lost in some of the technical language of the chapters on the neurobiology of aging males' sexuality, the effects of drugs and medications, and assessment. Although these chapters are obviously necessary, Schiavi probably could have expanded his target audience by using lay terms more frequently. This easily could have been accomplished by making the chapter summaries more accessible. Even though the chapter summaries are extraordinarily well constructed and inclusive of the appropriate points, I was dismayed by the recognition that these summaries and other sections of the book are just one step away from adaptation to patient education materials. This is particularly true for those sections dealing with Alzheimer's, prostate surgery, depression, and alcoholism.

The book also could have been improved by giving more attention to the case studies. They are inconsistent in quality, format, and development. They first appear at the end of Chapter 4 with minimal introduction and are then tacked to the end of subsequent chapters with token commentaries. Later, they are scattered throughout Chapter 12 with no commentary and little justification as to the reason for the shift in format. Questionable judgment is shown in a few of the commentaries. For example, no comment is made in one case study where a 68-year-old man denies ever having masturbated. No comment is made on an extramarital affair mentioned in another case where the patient includes it in his self-report. And the only time a personality disorder is mentioned in the text is in reference to a gay man and his "narcissistic personality" (p. 96), perpetuating a common, negative stereotype about gay men.

Finally, the last area of weakness in the book is its omission of a few topics. Although he regularly mentions that the research in this area is based on White, educated, privileged samples, Schiavi neglects to extend discussions of the implications of race, education, and class on the manifestation of disorders or their treatments. This is odd given his regular emphasis on psychosocial variables. In terms of sexual orientation, he devotes an entire chapter to homosexual relationships, but this material could have a greater impact by including it in each appropriate section throughout the text. Splitting this subject matter into a separate chapter is symbolic of the traditional way in which medical practitioners have handled lesbian, gay, and bisexual issues in the past. The topic of sexual orientation is mentioned only once again in the book, so it is easy to forget its prevalence as a pertinent treatment issue.

The book also neglects to attend to a number of relevant therapeutic matters. Schiavi seems to assume that readers will know how to take a complete sex history. Not only is this unlikely, but it minimizes the importance of a sex history and fails to provide readers with examples of useful frameworks and language to use in such a procedure. Further, Schiavi presumes that readers will agree with his theoretical stance of conducting separate assessment interviews with each member of a couple. There are numerous reasons why this might not be a good idea (e.g., the practitioner is expected to keep secrets), but the primary omission is the discussion of alternate viewpoints. This is also generally true of the chapter on treatment. Schiavi adopts a cognitive-behavioral psychotherapeutic approach and gives no mention of other possibilities.

The final omission of significance is that of an extended discussion on the use of sildenafil (e.g., Viagra) in the treatment of erectile dysfunction. Although a paragraph is devoted to this drug and its potential for becoming "a major breakthrough in the management of erectile dysfunction" (p. 228), the book appears to have been in press when the results of recent studies on sildenafil came to light. To his credit, Schiavi would have probably changed his book very little if the recent studies on sildenalfil had been published before his book went to press. His persistent emphasis on the interaction of psychosocial and biological determinants of dysfunctions would have resulted in few overall changes to the text.

Before concluding, the content of some of the more noteworthy chapters not already mentioned should be described. Schiavi has devoted entire chapters to aging and marital sexuality, the psychological aspects of aging males' sexuality, and the social context for aging males' sexuality in the U.S. Furthermore, throughout the book he embarks upon discussions of fascinating topics such as phantom orgasms, the role of androgen and androgen receptors in erectile dysfunction, the role of physical attractiveness in the relationships of aging couples, and the impact of dementia on sexual behavior.

All in all, the book's strengths far outweigh its flaws. Schiavi has composed a brilliant and comprehensive piece of work that is readily accessible as a training tool or as a reference handbook for practitioners and researchers alike in the field of male aging and sexuality. Readers will benefit especially from the methodological, theoretical, and sociological critiques offered by an expert who has distinguished his career and this book by his sensitivity, astuteness, and penetrating insightfulness.