Mature sexuality: patient realities and provider challenges.

Interest in sex is not limited to the young. Yet it is only in recent years that "mature sexuality" has begun to surface as a public issue, one that health care providers find themselves addressing with growing numbers of patients.

Our society's attitudes toward sexuality and patterns of sexual behavior have undergone dramatic changes in the course of a few decades. With the passage of time, those changed attitudes and behaviors are increasingly becoming those of the older generations as well as young.

Generational differences in those attitudes still exist: a poll conducted by The New York Times found that 55 percent of those under 30 think it is "okay" to fantasize about sex with someone other than their partner, compared to only 27 percent of those over 70. Forty-two percent of those under 30 favored legalizing same-sex marriages, but only 13 percent of those over 70 shared this view(1)

If the younger generations have more fully embraced attitudes toward sexuality that stand in marked contrast to those prevailing earlier in the twentieth century, many in the older generations are now openly acknowledging the important role that sexuality continues to play in their lives.

Recent studies refute old notions of aging as a period devoid of sex or sexual urges. Moreover, the entry into middle-age of the post-World War II baby boomers, the generation credited with bringing about the sexual revolution of the 1960s and 70s, can be expected to make the issue of senior sexuality an increasingly prominent one.

As one reporter commented, the "Boomers," whose mantra was once "Don't trust anybody over 30," are now discovering that "they don't lose their libido or become instantaneously impotent as they age and that the engine does not automatically shift into neutral and begin idling on a specific birthday."(2)

The availability of new therapies to combat problems associated with sexuality and aging will further ensure that Increasing numbers of older Americans enjoy an active sex life far longer than was thought possible, or even considered seemly, for earlier generations.

IMPLICATIONS FOR HEALTH PROFESSIONALS

The implications of these developments for health care providers are substantial. The expectations of growing numbers of older Americans will require providers to focus more attention on issues of mature sexuality. They must be educated about these issues, skilled in performing appropriate clinical assessments, and prepared to manage age-related sexual problems they may identify, including offering appropriate counseling and other services.

The Association of Reproductive Health Professionals (ARHP) has developed a Mature Sexuality Initiative to help prepare health professionals to meet these challenges. The goals of this initiative are consistent with ARHP's mission as an organization committed to educating professionals and patients on the broad spectrum of reproductive health issues.

This article is designed to help raise health professionals' awareness of mature sexuality as an issue they need to address. It will hopefully challenge both individual providers and other professional groups to help ensure that older Americans lead lives that are not only healthier and longer but also sexually rewarding.

SURVEYS

A 1979 Consumer Reports survey revealed more than 20 years ago that many older Americans were sexually active and open to discussing their sexuality. Numerous recent surveys have confirmed the importance of sexuality in the lives of many older adults. These surveys include:

* The 2000 Harris Interactive/PRIME PLUS/Red Hot Mamas (HI/PP) surveys of physicians, menopausal women, and partners of menopausal women

* The 1999 ARHP survey of 355 participants 50 years and older who were asked questions related to sexual behavior and attitudes

* The 1999 American Association of Retired Persons (AARP) survey of 1,384 men and women 45 years of age or older

* The 1998 National Council on Aging (NCOA) survey of 1,292 American 60 years of age and older

This article will review some of the findings of these surveys to give health professionals insight into the thoughts that older Americans have about sexuality issues and their own sex lives.

[Please note that the researchers conducting these surveys phrased their questions differently and surveyed varied age groups. Therefore, direct comparison of these studies is not possible. Although most of the research was weighted in order to generalize the results to the overall population in these age groups, some of the research (particularly among the oldest participants) is based on small samples.]

(See the SIECUS Fact Sheet on "Sexuality in Middle and Later Life" for more information on these surveys and their findings.)

FREQUENCY OF SEXUAL ACTIVITY 

The number of "mature" Americans who consider themselves sexually active declines with age. In addition, those who say they are sexually active also indicate a decline in the frequency of sexual relations.

The ARHP survey found that respondents engaging in any form of sexual activity--from kissing to "a night of passion--more than once a week" declined from 52 and 41 percent, respectively, for men and women in their fifties to 27 and 19.5 percent, respectively, for those 70 or older. (3)

The AARP survey reported that 77.3 percent of men and 71.7 percent of women between the ages of 45 and 59 engaged in kissing or hugging at least once a week compared to 63.3 percent of men 75 or older and 27.7 percent of women 75 or older.

The number of men reporting sexual intercourse at least weekly fell from 54.8 percent of those 45 through 59 years of age to 19.1 percent of those 75 or older. For women, those reporting sexual intercourse at least weekly fell from 49.6 percent (45 through 59 years of age) to 6.6 percent (75 or older).

A third of men between 45 and 59 reported "self stimulation," but this figure dropped to slightly more than five percent of men 75 and older. Few women of any age claimed to engage in self stimulation. (4)

The Harris Interactive/Prime Plus survey of postmenopausal women under 55 years of age reported that more than half had sexual relations at least once a week. Almost half (47 percent) reported a decrease in sexual activity since entering menopause; seven percent reported an increase in sexual activity, and approximately a third (36 percent) reported no change. (5)

AVAILABILITY OF SEXUAL PARTNERS

The availability of a sexual partner has a predictable effect on the level of a person's sexual activity.

According to the NCOA survey, among seniors with a sexual partner, the percentage who were sexually active climbed to 82 percent for men and 77 percent for women. (6)

Among married respondents to the Consumer Reports survey, 80 percent of wives and 77 percent of husbands reported current marital intercourse. (7) Unmarried men surveyed by Consumer Reports were more likely than their female counterparts to have a sexual partner: 57 percent reported an "ongoing" relationship, compared to only 33 percent of women. (8)

The relative lack of sexual partners among women in older age groups clearly contributes to the lower sexual activity levels they report. In the United States in 1996, the ratio of women to men in the 65-plus age group was 145 women for every 100 men; among those 85 or older, the ratio was 257 women for every 100 men. (9)

Pooled data from General Social Surveys between 1988 and 1991 indicated that, by ages 70 through 74, over 70 percent of women had had no sexual partners in the past year, compared to only 35 percent of men in the same age group. (10)

The AARP researchers found that, among those 75 and older, 78.6 percent of the women had no sexual partner, compared to only 42 percent of men. They concluded that "many of the gender differences found in this study appear to be related to the presence or absence of a sexual partner." (11)

Men are also more likely than women to have younger sexual partners, a factor that further exacerbates the problem of partner availability for older women. (12) Forty-three percent of men in their sixties who were surveyed by the NCOA reported sexual partners younger than themselves, compared with only 11 percent of women in the same age group. (13)

SEXUAL FUNCTIONING

Impairments in sexual functioning may explain much of the decline in frequency of sexual relations or the end of sexual activity that seems to accompany aging in most people.

The AARP study questioned both men and women regarding frequency of orgasm. The large majority (76.6 percent) of men 45 through 59 years of age said they "always" achieved orgasm. This figure dropped to 57 percent of men 60 through 74 years of age and to 48.1 percent among men 75 years of age or older. The number of women reporting they "always" had an orgasm was far lower than men in all age groups, but the decline with age was not as steep: 31.6 percent of women 45 through 59 claimed to "always" have an orgasm compared to 26 percent of those 60 through 74 years of age and 25 percent of those 75 or older. (14)

When asked if they ever suffered from impotence, men responding to the AARP survey provided very different answers depending on their age. Nearly 67 percent of men 45 through 59 described themselves as "not impotent." For those 60 through 74 years of age, this percentage dropped to 33.1 percent, with 27.6 percent reporting "minimal" impotence and nearly 16 percent reporting they were "completely" impotent. Among men 75 and older, only 18.4 percent said they 'were "not impotent" and the number reporting "complete" impotence had risen to nearly 38 percent. Another 19.3 percent of men in this oldest age group reported "moderate" impotence. (15)

LEVEL OF SEXUAL DESIRE

While sexual desire remains relatively high among both men and women as they age, there is a clear decline in the level of sexual desire that accompanies advancing age.

Among participants in the NCOA survey, nearly half of all men and women with sexual partners, and 55 percent of less active men and women, said they had less physical desire for sexual relations than in the past. (16) More than four in 10 women participating in the HI/PP survey reported a decrease in sexual desire following menopause. (17)

The AARP survey asked participants how often they experienced sexual desire; 57 percent of all surveyed men claimed to feel sexual desire at least two to three times per week, compared to 22.2 percent of all surveyed women. Frequency of sexual thoughts in men declined dramatically with increasing age.

The presence of a partner influenced frequency of sexual thoughts. Among men with sexual partners, 70 percent claimed sexual thoughts once a week or more often, compared to 57 percent of men without partners. Only 36 percent of women with partners reported sexual thoughts at least weekly, and even fewer women without partners (12 percent) said they thought about sexual relations at least once a week.

Nearly half of women without partners (47.8 percent) said they never had sexual thoughts, compared to only 10.2 percent of men without partners. The number of respondents reporting sexual thoughts at least weekly declined in both sexes with increasing age. (18)

SATISFACTION WITH SEXUAL ACTIVITY

If older Americans tend to engage in sexual activity somewhat less often than younger age groups, this does not necessarily mean they are less satisfied with their sex lives.

The ARHP survey found that the percentage of those declaring themselves "satisfied" with their sex life was in most cases higher than the percentage claiming to be sexually active.

Not quite 62 percent of men in their fifties claimed to be sexually active, but 69.5 percent said they were either "very" or "somewhat" satisfied with their sex lives. In this same age group, 24.5 percent of men said they were not sexually active, but only 13.6 percent expressed dissatisfaction with their sex life. A similar pattern prevailed for women in their fifties.

The percentage of men who were dissatisfied with their sex life increased with age, while the percentage of women who were dissatisfied declined.

When participants in the ARHP survey were asked to compare their current sex life to that when they were younger, approximately 56 percent of men in their fifties and 51.5 percent of women in the same age group described themselves as currently "more satisfied" or "equally satisfied" with their sex life, compared to when they were younger.

ARHP also asked a related question: "Do you consider yourself to be a better lover than you were in the past?" Most men 50 through 59 years of age (54.3 percent) considered themselves to be better lovers than in the past, compared to only 33.5 percent of men 70 or olden For women 50 though 59 years of age, a minority (37.6 percent) thought themselves better lovers now than in the past, and that number fell to 24.1 percent among women 70 and older. (19)

The NCOA survey found that, among seniors with current sex partners, approximately 60 percent of both men and women 60 years of age or older considered their sex life physically "more satisfying" or "unchanged" from when they were in their forties.

Asked about the emotional satisfaction they derived from sexual relations, 74 percent of sexually active men and 70 percent of sexually active women stated that they were "more satisfied" or "as satisfied" as when they were in their forties. Reasons given for greater emotional satisfaction included: a new marriage or different relationship, being more in touch with one's partner, no longer distracted by children, more time to enjoy sexual relations, and less stress. (20)

When asked if they were satisfied with the frequency of sexual relations in their personal lives, 35 percent of the men and 42 percent of the women in the NCOA survey reported being satisfied. Among those seniors with partners, the number of those satisfied with the frequency of sexual relations increased to 42 percent of all men and 65 percent of all women. In every age group, men were more likely than women to say they would like to have more frequent sexual relations (56 percent of all men versus 25 percent of all women). (21)

AARP's survey, the most comprehensive in the group reviewed, also addressed the issue of sexual satisfaction. It found women more likely than men in all age groups to report being "extremely" satisfied with their sex life, but men and women were equally likely to be either "extremely" or "somewhat" satisfied.

When asked about changes that would increase their satisfaction, frequent responses by both men and women included better health for themselves or their partner, less stress, and more free time. Men, as they aged, increasingly reported their own health as their main concern, while women were more apt to cite their partner's health rather than their own. Older women were more likely than older men to identify "finding a partner" as a needed change. In the 75 and older age group, approximately one-third of both men and women reported that no change was needed (compared to 17.8 percent of men and 22.2 percent of women in the 45 to 59 age group).

SEXUAL DYSFUNCTION IN LATER YEARS

A growing body of research is exploring the problem of sexual dysfunction--disturbances in sexual desire and in the psychophysiological changes associated with the sexual response cycle in men and women. (22)

The physiological effects of aging are thought to result in certain types of sexual dysfunction. (23) A slowing of the process by which sexual arousal and climax are achieved is common in older adults but may sometimes enhance rather than impair sexual relations since "it may permit a better response synchronization between the sexes, compared to that in earlier years when men responded more quickly than women." (24)

Moreover, certain aspects of mature sexuality, such as declining frequency, may have other explanations than age-related physiological changes. As Laumann and Youm noted in their report to the 1999 Conference on Sexuality in Midlife, "predictability and routinization of sex" may contribute to decreased incidence of sexual activity in a long-term relationship; declining frequencies of sexual activity in older couples "may have as much to do, then, with the length and nature of their interpersonal relationships and other network obligations (to children, aging parents) as they do with the physiological effect of aging per se." (25)

A variety of medical conditions, ranging from heart disease to arthritis, can affect sexual functioning. The presence of these conditions does not, however, mean that sexual activity is contraindicated. In some cases, sexual activity may actually have therapeutic value. (26) Health professionals caring for patients with these conditions must be prepared to counsel and often to reassure them about the advisability or safety of sexual activity.

SEXUAL DYSFUNCTION IN OLDER ADULTS

Identifying the presence of sexual dysfunction involves the application of appropriate assessment guidelines. A number of tools have been developed to facilitate sexual history taking and assessment, ranging from brief to comprehensive, (27) and researchers continue working to improve methods for identifying and evaluating both psychological and physiological indicators of sexual dysfunction. (28)

If sexual dysfunction is present, the provider must then determine if the cause is, in fact, age-related or reflects other problems, such as earlier sexual patterns and problems, medical conditions, the results of surgery, or side effects of medication. (29)

The provider must also consider whether identified measures of sexual dysfunction in older patients signal problems requiring treatment. Survey data cited earlier suggest that many older Americans are satisfied with their existing level of sexual activity, even if it is lower than at earlier stages of life. Some men may be content to learn that a perceived problem is considered "normal" for their age and not reflective of an underlying, more serious health problem. (30)

For those seniors without a partner, lack of sexual desire may serve a very useful purpose, and is perhaps responsible for the high levels of satisfaction with their current sex life claimed by so many adults in the oldest age groups surveyed.

Evaluation of sexual dysfunction in older adults who do have partners should involve both patient and partner. The effect of treatment on the relationship with that partner must be taken into account: will it resolve a problem, or create one?

* The husband who uses a testosterone gel only to discover that his wife does not respond to his newly revived sexual overtures may experience a sexual frustration that undermines a longstanding relationship

* Estrogen-androgen therapy for a woman whose husband regularly experiences impotence may create sexual tension that previously did not exist and necessitate further intervention--with unpredictable results

As a general rule, therapy to increase libido or otherwise enhance sexual desire or performance should be considered only if the patient expresses dissatisfaction with his or her current status, there is sexual incompatibility with a partner which therapy may correct, and the partner understands and supports any proposed intervention.

For many older patients, intervention to improve sexual functioning will certainly be appropriate and welcome. In some cases, patient education or referral for counseling and behavioral strategies may be effective. In others, medication may offer the most effective treatment strategy.

MEDICAL TREATMENT OPTIONS

Hormone replacement therapy (HRT) has become a standard treatment for menopausal symptoms in women, relieving overt symptoms such as "hot flashes" and vaginal dryness, as well as increasing clitoral blood flow and decreasing vaginal atrophic changes. (31) The use of combination hormonal therapy (estrogen plus progestin) has increasingly replaced the use of estrogen alone. More recently, testosterone has come into use as a component of HRT for some women experiencing diminished libido, which may be unaffected by estrogen. (32)

Testosterone is considered the hormone of sexual drive in women. (33) Its deficiency appears to have multiple negative affects on female sexuality, among them global loss of sexual desire, decreased sensitivity to sexual stimulation in the nipples and clitoris, and decreased arousal and capacity for orgasm. (34) The importance of testosterone in maintaining a woman s sexual vitality is a persuasive argument for considering replacement therapy for postmenopausal women, who lose approximately 50 percent of their total androgen production. (35)

There is no clear consensus on the value of testosterone therapy as a treatment for diminished sexual desire secondary to androgen deficiency in men. A trend toward increased arousal and spontaneous erection during administration of exogenous testosterone did not reach statistical significance in one study, which also found no change in frequency of sexual intercourse, masturbation, kissing and fondling, or satisfaction in sexual relationships. (36)

A double-blind, placebo-controlled crossover study conducted with healthy men experiencing erectile dysfunction found that ejaculatory frequency increased with testosterone treatment and that there were "marked, although statistically non-significant increases in median frequency of reported sexual desire, masturbation, sexual experiences with partner, and sleep erections." No effects on ratings of penile rigidity or sexual satisfaction were observed. (37)

Other studies claim effects of testosterone therapy on men's sexual interest, arousal and enjoyment. (38) Early this year, the Food and Drug Administration (FDA) approved a testosterone gel (AndroGel[R]) for treatment of hypogonadism in men. Clinical studies conducted by the manufacturer found that once-daily application of the gel to arms, shoulders and/or abdomen raised circulating levels of testosterone into the normal range; increased sex drive, bone density and lean body mass; reduced fatigue, and improved mood. (39)

The effectiveness of sildenafil (Viagra[R]) has "revolutionized" the treatment of erectile dysfunction (ED) in men, ushering in a new era in which oral medications will likely dominate the management of ED as well as other forms of sexual dysfunction. (40)

Sildenafil acts by inhibiting phosphodiesterase type 5, allowing corpus cavernosum smooth muscle to relax and thus increasing penile response to sexual stimulation. (41) Generally well--tolerated, sildenafil is nonetheless contraindicated in patients receiving nitric oxide donor drugs, isosorbide mononitrate (ISMN) or glyceryl trinitrate (GTN) for angina, as it potentiates the hypotensive effects of nitrates. (42)

Alternative oral medications to treat ED are being investigated. Oral phentolamine (Vasomax[R]) is now available and, while results of clinical trials suggest it may not be as effective as sildenafil, its major documented side effect is rhinitis--experienced by 7.7 percent of clinical trial participants. (43) It has been noted that the end points of impotence treatment studies are diverse, and no long term comparison studies have been performed. (44)

The use of sildenafil in treating female sexual dysfunction has also been investigated, with varying results. A study involving women with spinal cord injuries suggests that neurogenic sexual dysfunction in women may be partially reversed by treatment with sildenafil. (45) Both men and women suffering from psychotropic-induced sexual dysfunction reported significant improvements in both sexual functioning and overall sexual satisfaction following treatment with sildenafil, although patients taking selective serotonin re-uptake inhibitors (SSRIs) reported less improvement than others. (46)

A study with estrogenized women experiencing female sexual arousal disorder found no improvement in the sexual response of these women. (47) A safety and efficacy study in postmenopausal women also found that "overall sexual function did not improve significantly, although there were changes in vaginal lubrication and clitoral sensitivity. The role of sildenafil in treating sexual dysfunction in various cohorts of women remains to be determined." (48)

PATIENT-PROVIDER COMMUNICATION

Open communication between health care provider and patient is essential to identifying and addressing sexual problems effectively. Yet surveys suggest that such communication is the exception rather than the rule.

The Harris Interactive/Prime Plus (HI/PP) physician survey, conducted in January 2000, included 158 obstetrician/gynecologists and 143 primary care physicians. Findings from this survey, as well as those from the parallel survey of menopausal women, suggest that inadequate physician-patient communication may be a substantial barrier to maximizing older women's satisfaction with their sexual lives. (49)

The physicians surveyed estimated that nearly half of their patients will experience sexuality problems as a result of menopause, but only about 50 percent of these physicians reported asking their patients about sexual desire as part of a routine gynecological exam. Even fewer ask about patients' sexual satisfaction and sexual response. The large majority of these physicians said they were "very comfortable" or "somewhat" comfortable discussing sexual problems with their patients, but believed that only "some" or "relatively few" of their patients were comfortable talking to them about such problems.

Among the women surveyed by HI/PP, approximately 75 percent said they felt "very" or "somewhat" comfortable discussing sexual issues with their physician, and more than half (56 percent) said their physician was the person with whom they would be most likely to discuss a sexual problem.

Yet a majority of postmenopausal women in the survey, all under 55 years of age, claimed that their physician either "never" initiates discussion of sexual health, or does so only when the patient first raises the subject. More than half of the physicians surveyed agreed that, when they discuss a sexual problem with a menopausal patient, it is more likely the patient rather than themselves who initiates it. (50)

Menopausal women are not alone in perceiving problems in communicating with their physician about sexual matters. A poll of a broader group of U.S. adults 25 years of age or older found that 71 percent thought their doctor would dismiss concerns they raised about sexual problems. Even more (85 percent) said they would nonetheless raise the issue with their physician.

The poll results, reported at a 1999 conference on Gender and Human Sexuality; also found that 68 percent of those polled who acknowledged sexual problems said they thought discussing them would embarrass their physician. (51) Physicians themselves recognize personal embarrassment as a barrier for many in taking a patient's sexual history. (52) Lack of time or inadequate knowledge may also inhibit provider communication with patients on matters of sexuality. (53)

Male patients tend to be indirect rather than straightforward in addressing health issues and may be less likely than female patients to discuss sexual problems with their physician or other health care provider. A number of barriers may prevent men from bringing health concerns to their physician:

* Sense of immunity from health problems

* Difficulty in relinquishing control

* Belief that seeking help is unacceptable

* Time and access

* Having to state the reason for their visit to the provider

* Not having a male provider (54)

A first step for providers in breaking down communication barriers with their male patients may be to become thoroughly familiar with conditions and risk factors associated with sexual disorders such as ED. (55)

The intimate nature of sexuality clearly poses special challenges to providers in discussing it with their patients.

The skills required are not routinely included in the training of physicians or other health professionals. Using appropriate sexual history-taking strategies and other techniques for raising issues of sexuality with their patients, providers can increase their level of comfort in discussing these issues and do so in a way that is non-threatening to patients and responds to their needs and concerns.

CONCLUSIONS

There is ample evidence that a great many older adults continue to engage in sexual activity well into old age and derive substantial satisfaction and enjoyment from it.

There is also evidence that many older Americans experience sexual dysfunction of one form or another and are dissatisfied with the resulting impact on their quality of life. A broadening array of treatments is available to address these problems when such treatment seems in the best interest of the patient.

Providers are not always sensitive to the importance that older patients attach to problems of sexuality. They also may not be skilled in eliciting information about such problems or comfortable addressing them. Greater provider awareness of these issues is needed, along with adequate training in their assessment, diagnosis, and treatment.

Educational institutions that train health professionals must be encouraged to place increased emphasis on the care of older adults in general, including their sexuality. Professional organizations can also play a large role in bringing about these improvements in provider understanding and performance, both as advocates for supportive professional policies and standards and as the source of ongoing, continuing education for their members.

Additional research is also needed. We must refine our understanding of sexual functioning and the determinants of sexual satisfaction at older ages and be able to measure them in order to diagnose and treat potential problems accurately and appropriately. Long-term evaluation of recently introduced treatment methods is needed at the same time that even newer treatments are being developed and tested.

An informal poll by ARHP of recognized experts in the field of mature sexuality pinpointed a number of specific research needs:

* Negotiation and execution of sexual interaction among mature adults

* Effects of the relationship with the sexual partner on sexual expression

* Securing access to sexual partners among mature adults

* More exploration of male and female sexual dysfunction

* Changes in sexual functioning with age

* Effects of medications and other interventions on sexual functioning

* Patterns of sexual beliefs and behaviors in older populations, including impact of specific demographic characteristics

* Impact of specific conditions (incontinence, pelvic organ prolapse, heart disease) on sexual function

* AIDS in the elderly

This list is by no means comprehensive, but it suggests the breadth of knowledge yet to be acquired about sexuality in the later decades of life. That knowledge will continue to grow, and with it, our ability to treat problems of sexuality among older adults. The public can be expected to embrace these new treatments in much the same way they have those already available. The education and training of health professionals must also keep pace.

(This article was adapted with permission of the Association of Reproductive Health Professionals from their September 2000 publication ARHP Clinical Proceedings.)

Editor

REFERENCES

(1.) "The Way We Live Now Poll," The New York Times Magazine, May 7, 2000.

(2.) The San Francisco Examiner, San Francisco, CA, November 17, 1999.

(3.) Sexual Activity Survey (Washington, DC: National Association of Reproductive Health Professionals, April 1999).

(4.) AARP/Modern Maturity Sexuality Study (Washington, DC: American Association of Retired Persons, 1999).

(5.) Sexual Communications Survey (Ridgefield, CT: PRIME PLUS/Red Hot Mamas, 2000).

(6.) Healthy Sexuality and Vital Aging (Washington, DC: National Council on Aging, 1998).

(7.) E. M. Brecher, Love, Sex and Aging: A Consumers Union Report (Boston: Little Brown and Company, 1984).

(8.) Ibid.

(9.) Healthy Sexuality and Vital Aging.

(10.) E. O. Laumann and Y. Youm, The Effects of Aging on Male and Female Sexuality (Conference on Sexuality in Midlife, Kinsey Institute for Research in Sex, Gender and Reproduction and Sexuality Information and Education Council of the United States, 1999.)

(11.) AARP/Modern Maturity Sexuality Study.

(12.) E. O. Laumann and Y. Youm, The Effects of Aging on Male and Female Sexuality.

(13.) Healthy Sexuality and Vital Aging.

(14.) AARP/Modern Maturity Sexuality Study.

(15.) Ibid.

(16.) Healthy Sexuality and Vital Aging.

(17.) Sexual Communications Survey.

(18.) Ibid.

(19.) Sexual Activity Survey.

(20.) Healthy Sexuality and Vital Aging.

(21.) Ibid.

(22.) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Washington, DC: American Psychiatric Association, 1994), pp. 498-522.

(23.) D. L. Rowland, WJ. Greenleaf, L.J. Dorfman, J. M. Davidson, "Aging and Sexual Function in Men, Archives of Sexual Behavior, vol. 22, pp. 545-57; R. C. Rosen, J. F. Taylor, S. R. Leiblum, and G. A. Bachmann, "Prevalence of Sexual Dysfunction in Women: Results of a Survey Study of 329 Women in an Outpatient Gynecological Clinic," Journal of Sex and Marital Therapy, vol. 19, no. 3, pp. 171-88.

(24.) W. B. Abrams, M. H. Beers, and R. Berkow, editors, The Merck Manual of Geriatrics, Second Edition (Whitehouse Station, NJ: Merck & Co., Inc., 1995), chapter 68.

(25.) E. O. Laumann and Y. Youm, The Effects of Aging on Male and Female Sexuality.

(26.) W. B. Abrams, et al., editors, The Merck Manual of Geriatrics, Second Edition, chapter 68.

(27.) W. C. Andrews, "Approaches to Taking a Sexual History," Journal of Women's Health & Gender-based Medicine, vol. 9, supplement 1, pp. S21-4.

(28.) R. Rogers, A. Villarreal, D. Kammerer-Doak, A. Villarreal, K. Coates, and C. Qualls, "A New Instrument to Measure Sexual Function in Women with Urinary Incontinence and/or Pelvic Organ Prolapse," International Urogynecological Journal, vol. 10, supplement 2, p. S10.

(29.) R. C. Schiavi and J. Rehman, "Sexuality and Aging," Urology Clinicians of North America, vol. 22, no. 4, pp. 711-26.

(30.) J. K. Warnock, et al., "Female Hypoactive Sexual Disorder: Case Studies of Physiologic Androgen Replacement," pp. 175-82.

(31.) P. M. Sarrel, "The Differential Effects of Oestrogens and Progestins on Vascular Tone," Human Reproduction Update, vol. 5, no. 3, pp. 205-9.

(32.) C. S. Myers, et al., "Effect of Estrogen, Androgen, and Progestin on Sexual Psychophysiology and Behavior in Post-menopausal Women," Journal of Endocrinology and Metabolism, vol. 70, no. 4, pp. 1124-31.

(33.) R. Sands and J. Studd, "Exogenous Androgens in Postmenopausal Women," American Journal of Medicine, vol. 98, supplement 1A, pp. 76s-79s.

(34.) S. Rako, The Hormone of Desire: The Truth about Sexuality, Menopause and Testosterone (New York: Harmony Books, 1996).

(35.) C. Longcope, C. Bourget, and C. Flood, "The Production and Aromatization of Dehydroepiandrosterone in Post-menopausal Women," Maturitas, vol. 4, no. 4, pp. 325-32.

(36.) C. J. Bagatell, J. R. Heiman, A. M. Matsumoto, J. B. Rivier, and W J. Bremner, "Metabolic and Behavioral Effects of High-dose, Exogenous Testosterone in Healthy Men' Journal of Clinical Endocronology and Metabolism, vol.79, no. 2, pp. 561-7.

(37.) R. C. Schiavi, D. White, et al., "Effect of Testosterone Administration on Sexual Behavior and Mood in Men with Erectile Dysfunction," Archives of Sexual Behavior, vol. 26, no. 3, pp. 231-41.

(38.) G. M. Alexander, R. S. Swerdloff, et al., "Androgen-behavior Correlations in Hypogonadal Men and Eugonadal Men," Hormonal Behavior, vol. 31, no. 2, pp. 110-19.

(39.) Data on file. Unlined Pharmaceuticals, Inc., Buffalo Grove, IL, 2000.

(40.) I. I. Moncada and I. saenz de Tejada, "Pharmacological Treatment of Erectile Dysfunction," Current Opinion on Urology, vol. 9, no. 6, pp. 547-51; H. Padma-Nathan, "A New Era in the Treatment of Erectile Dysfunction," American Journal of Cardiology, vol. 84, no. 5B, pp. 18-23N.

(41.) I. Goldstein, T. F. Lue, H. Padma-Nathan, R. C. Rosen, W D. Steers, and P. A. Wicker, "Oral Sildenafil in the Treatment of Erectile Dysfunction, Sildenafil Study Group," New England Journal of Medicine, vol. 338, no. 20, pp. 1397-404.

(42.) D.J. Webb, G.J. Muirhead, M. Wulff, J.A. Sutton, R. Levi, and W W Dinsmore, "Sildenaffi Citrate Potentiates the Hypotensive Effects of Nitric Oxide Donor Drugs in Male Patients with Stable Angina," Journal of the American College of Cardiology, vol. 36, no. 1, pp. 25-31.

(43.) I. Goldstein, "Oral Phentolamine: An Alpha-1, Alpha-2 Adrenergic Antagonist for the Treatment of Erectile Dysfunction, International Journal of Importance Research, March 2000, supplement 12, pp. S75-80.

(44.) W Meinhardt, R. E Kropman, and P. Vermeij, "Comparative Tolerability and Efficacy of Treatments for Impotence," Drug Safety, vol. 20, no. 2, pp. 133-46.

(45.) M. L. Sipski, R. C. Rosen, C. J. Alexander, and R. M. Hamer, "Sildenafil Effects on Sexual and Cardiovascular Responses in Women with Spinal Cord Injuries," Urology, vol. 55, no. 6, pp. 812-5.

(46.) A. J. Salerian, W E. Deibler, B. J. Vittone, S. P. Geyer, L. Drell, N.) Mirmirani, J. A. Mirczak, W Byrd, S. B. Tunick, M. Wax, and S. Fleisher, "Sildenafil for Psychotropic-induced Sexual Dysfunction in 31 Women and 61 Men, Journal of Sexual and Marital Therapy, vol. 26, no. 2, pp. 133-40.

(47.) R. Basson, R. McInnes, M.D. Smith, G. Hodgson, T. Spain, and N. Koppiker, "Efficacy and Safety of Sildenafil in Estrogenized Women with Sexual Dysfunction Associated with Female Sexual Arousal Disorder," Obstetrics and Gynecologists, vol. 95, no. 4, supplement 1, p. S54.

(48.) S. A. Kaplan, R. B. Reis, I. J. Kohn, E. E Ikeguchi, E. Laor, A. E. Te, A. C. Martins, "Safety and Efficacy of Sildenafil in Postmenopausal Women with Sexual Dysfunction," Urology, vol. 53, no. 3, pp. 481-6.

(49.) Sexual Communications Survey.

(50.) Ibid.

(51.) C. Marwick, "Survey Says Patients Expect Little Physician Help on Sex,,, Journal of the American Medical Association, June 1999, p. 281.

(52.) J. M. Merrill, L. F. Laux, and J. I. Thornby, "Why Doctors Have Difficulty with Sex Histories:' Southern Medical Journal, vol. 83, pp. 613-17.

(53.) L. Herson, K.A. Hart, M. J. Gordon, D. H. Rintala, "Identifying and Overcoming Barriers to Providing Sexuality Information in the Clinical Setting," Rehabilitation Nurses, July-August 1999, pp. 148-51.

(54.) F. Tudiver and Y. Talbor, "Why Don't Men Seek Help? Family Physician's Perspectives on Help-seeking Behavior in Men," Journal of Family Practice, vol. 48, pp. 47-52.

(55.) 5. G. Korenmnan, "New Insights into Erectile Dysfunction: A Practical Approach," American Journal of Medicine, vol. 105, no. 2, pp. 135-44.

RELATED ARTICLE: ARHP'S MATURE SEXUALITY INITIATIVE

The Association of Reproductive Health Professionals (ARHP) has launched a Mature Sexuality Initiative that will include publications and education efforts aimed at older individuals, their medical practitioners, and the public.

The article "Mature Sexuality: Patient Realities and Provider Challenges" in this issue of the SIECUS Report is adapted from an issue of ARHP's Clinical Proceedings published as part of the Initiative.

The Initiative's goal is to promote a better understanding for health care providers of the unique needs of their older patients.

ARHP welcomes input on its Mature Sexuality Initiative. Please contact author Katherine Lacy, ARHP, 2401 Pennsylvania Avenue, N.W., Suite 350, Washington, DC 20077-6710. Phone: [phone]. Fax: [phone]. E-mail: arhp @arhp.org. Web site: www.arhp.org