Women's sexuality as they age: the more things change, the more they stay the same.

With the aging of the baby boomers and the development and hugely successful marketing of Viagra[R] to treat erectile dysfunction, attention from sexologists, pharmaceutical companies, and the public has become focused on the sexuality of aging women. (1)

Some of the burning questions that are currently being pursued are: Does women's sexual functioning (sexual desire, arousal, orgasm, activity, and/or satisfaction) decrease with age and/or menopausal status? And what can be done to enhance aging women's sexual functioning?

As researchers try to provide answers for women, pharmaceutical companies, and other interested parties, what is becoming crystal clear is that we (the scientific community, health care professionals, and society at large) don't understand women's sexuality as they age because we don't understand women's sexuality. Therefore, we may not even be pursuing the right questions. For example, are specific elements of sexual "functioning" the most important aspects of women's sexuality or do we need to shift our focus?

MODELS OF FEMALE SEXUALITY: THE IMPORTANCE OF CONTEXT

Much of the information accumulated about women's sexuality has been generated from theories, research methodologies, and interpretation of data based on male models of sexuality, sexual functioning, and scientific inquiry.

As explained by Ray Rosen, Ph.D., at a recent conference on "Emerging Concepts in Women's Health," sexology has pursued a path of treating male and female functioning as similar, as evidenced by Masters and Johnson's development of the human sexual response cycle. (2)

What has resulted is a lack of appreciation for and documentation of the unique aspects of women's sexual functioning and expression. There is a growing chorus of sexologists acknowledging that women's sexuality, including their sexual response, merits different models than those developed for men. (3)

As Leonore Tiefer, Ph.D, has advocated, what is needed is a model of women's sexuality that is more "psychologically-minded, individually variable, interpersonally oriented, and socioculturally sophisticated." (4) Such models are beginning to emerge. (5)

The new models of female sexual response have been developed from quantitative and qualitative research findings and clinical practice assessments that more accurately reflect women's actual experiences than previous male- centered models.

A key component of these models is the importance of context to women's sexual expression. Context has been defined as "the whole situation, background, or environment relevant to some happening." (6) For example, unlike men whose sexual desire often is independent of context, women 's sexual desire is often a responsive reaction to the context (her partner's sexual arousal, expressions of love and intimacy) rather than a spontaneous event. (7) Jordan identified the central dynamic of female adolescent sexuality as the relational context. (8) She described young women's sexual desire as actually being "desire for the experience of joining toward and joining in something that thereby becomes greater than the separate selves." (9)

So throughout women's development and the transitions in their lives (adolescence, pregnancy, parenthood, menopause) context is a key factor in their sexual expression. Thus, the more things change (their bodies, their relationships, their circumstances), the more they stay the same (the importance of context to their sexual expression).

INSIGHTS FROM THE MIDLIFE WOMEN'S HEALTH SURVEY

Applying the new models of women's sexuality that emphasize the importance of context helps us to better understand women's sexuality as they age. Findings from the Midlife Women's Health Survey (MWHS), a longitudinal study of the menopausal transition that is part of the broader Tremin Trust Research Program on Women s Health, support these new models. (10)

The Tremin Trust is a longitudinal, intergenerational study focusing on menstrual health that first enrolled 2,350 university women in 1934 and a second cohort of 1,600 young women between 1961 and 1963. (See the Tremin Trust Web site at www.pop.psu.edu/tremin/). In 1990, an additional 347 mid-life women were enrolled in order to better study various aspects of the menopausal transition, including sexual changes.

All the participants complete a daily menstrual calendar, recording detailed information about their menstrual health. They also complete a yearly comprehensive survey, assessing biopsychosocial information about their health and aging, life experiences, and sexuality among other factors. These surveys collect both quantitative and qualitative data. Throughout the years, some of the women have been called upon to participate in special qualitative studies in which they have been interviewed. One hundred of the perimenopausal women who are not taking hormone replacement therapy have also supplied daily morning urine specimens so that hormonal analysis could be conducted.

The Tremin Trust participants are incredibly dedicated to the project. For example, they keep daily records throughout their lives (for some almost 70 years) and enlist participation from their daughters, granddaughters, and great-granddaughters. The study's potential for providing a greater understanding of women's sexuality throughout their lives, and the factors that affect sexual changes, is unparalleled. The greatest limitation is the lack of diversity among the participants, since over 90 percent are well-educated white women. However, data collection has been conducted with additional samples of African-American and Alaskan women as well as lesbians. More diverse cohorts may be enlisted in the future.

Analysis of the sexuality data is ongoing, with more data being collected each year. Interesting findings have emerged regarding midlife women's sexuality (ages 35 through 55 years of age) as they progress through menopausal transition. The average age of menopause is 51, with perimenopause beginning as early as the late thirties. In an open-ended question asking what they enjoyed most about their sexuality, more than two-thirds of the women referred to aspects of their relationships with their partner. (11) Most of these responses described some aspect of intimacy, including love, closeness, sharing, companionship, affection, and caring, as described below. About 15 percent of the women noted feeling comfortable and secure in their relationship, emphasizing feelings of mutual trust and honesty.

It is the most healthy relationship I've ever been in. Sex in the context of a respectful, caring, non-exploitative relationship is very wonderful.

Wow! The sexual experience is another heightened way we share the humor that comes from shared experiences such as canoeing, fine music, backyard work, scuba trips. It makes the "union" a joyous and complete one!

Many of the lesbian participants felt that the intimacy they shared in their relationships was even greater than what they had experienced or observed in male-female relationships.

Many straight women in 20-to-25-year marriages are distant and emotionally separate from their husbands. I think this is a time when lesbian women and their partners really come into their own-- their best time together. There's much greater emotional intimacy with less emphasis on sex. It's very nurturing and increases the bond between us.

Another very important contextual feature that at least one in ten women enjoyed about their sexuality was a newly-found sexual freedom they experienced as they aged, either from their children leaving home or from being with a new partner.

Freedom and ability to be spontaneous with our sexual desires due to the "empty nest."

The freedom to have sex at his apartment. The growing intimacy and closeness that goes along with sex itself The sexual playfulness and frivolity that threads itself through regular daily activities (teasing, sexual nuances, private jokes, and touches).

Approximately 20 percent of the women discussed some particular aspect of their sexual interactions, with mutual sexual satisfaction, continuing sexual interest, desire, and attraction, and lessened inhibitions and increased experimentation mentioned most often.

We seem to enjoy sex more and more as the years go by. The orgasms seem even better. We both respond well to each other sexually since we feel safe in our loving monogamous relationship.

One-third of these discussions emphasized that touching, kissing, hugging, and cuddling were the most important aspects of the sexual interactions.

You may not consider it sexual, but sleeping together in a queen-sized bed in the last year and a half. While the kids were growing up, we had twin beds. We enjoy the cuddling this provides daily.

Qualities exhibited by their sexual partners, who are most often the women's husbands, have been found to significantly impact the women's sexual responding. (12) Specifically, the more love, affection, passion, assertiveness, interest, and equality expressed by the sexual partners, the higher the women's sexual desire, arousal, frequency, and enjoyment. Women also expressed appreciation for a non-demanding partner who was responsive to their needs.

My partner is very accepting about how I feel and what I like and what I don't like even though it changes often. I also appreciate that he doesn't expect me to have an orgasm every time we make love.

SEXUAL CHANGES AS WOMEN AGE

Each year the women report many changes in their sexual responding. Some women have reported enjoying sex more (8.7 percent), easier arousal (8.7 percent), desiring sexual relations more (7 percent), easier orgasm (6.7 percent), and engaging in sexual relations more often (4.7 percent). (13) The women attribute their improved sexuality most often to changes in life circumstances (new partner, more freedom with children leaving home), improved emotional well-being, more positive feelings toward partner, and improved appearance. (14)

However, two to three times more women have reported declines in their sexual responding, including: desiring sexual relations less (23.1 percent), engaging in sexual relations less often (20.7 percent), desiring more non-genital touching (19.7 percent), more difficult arousal (19.1 percent), enjoying sexual relations less (15.4 percent), more difficult orgasm (14 percent), and more pain (10 percent).

Women are much more likely to attribute declining sexual response to physical changes of menopause than to other factors. (15) Analysis of the health data has found a statistically significant relationship between having vaginal dryness and decreased sexual desire and enjoyment. (16) However, no statistically significant relationship between menopausal status and decreased sexual desire, enjoyment, or more difficulty with orgasm was found. On the other hand, sexual desire and enjoyment were significantly related to marital status, with decreases associated with being married. The woman's age was also significantly related to her sexual enjoyment, with enjoyment decreasing as the woman became older. Further, a significant relationship has been found between poor body image and decreased sexual satisfaction. (17)

Other studies among general populations of aging women have failed to find clear associations between menopausal status and declines in sexual functioning. (18) Similar to the MWHS findings, they found psychosocial factors to be more important determinants of sexual responding among midlife (perimenopausal and menopausal) women than menopausal status. (19) The factors include sexual attitudes and knowledge; previous sexual behavior and enjoyment; length and quality of relationship; physical and mental health; body image and self-esteem; stress; and partner availability, health, and sexual functioning.

SEXUAL SATISFACTION AND THE IMPORTANCE OF SEX FOR WOMEN

Even with many aging women in the MWHS identifying declines in their sexual desire, frequency, or functioning, almost three-quarters of them reported overall sexual satisfaction (71 percent), including being physically and emotionally satisfied (72 percent).

Even though sex is less frequent and it takes much longer to feel turned on, it is still very satisfying.

I have been a very fortunate person. The man I married I still love dearly. We both respect each other and try to keep each other happy. We don't have sex as much as we used to but we kiss and hug and hold each other a lot.

The importance of sexual expression varied in the midlife women's lives and was affected by the circumstances in which they found themselves (married, divorced, widowed, in a same-sex relationship). Once again, women evaluated the importance of sexuality in the overall context of their lives. Some women who had lost their sexual partners to death or divorce reported missing a sexual relationship, mostly because of the lack of intimacy.

I find being a widow at a young age to be very lonely. I find that I miss the desire to have a sexual closeness with a man. I also feel very sad and confused as my husband was the only man I have ever been with. Having lost him, I fear beginning a new relationship.

I have been alone for 18 years after a 14 year marriage and three children. I miss regular sex, but most of all I miss touching, cuddling, body-to-body contact, not the sex act.

Yet many women without partners had decided that having sexual relations was not worth the price if the overall relationship was not fulfilling.

I am single by choice (heterosexual) and have never wanted children. I am finding it difficult to meet men as I get older and my relationships are further apart. My sexual response is still very strong, but I am not willing to compromise what I want in a relationship just for sex. My attitude is that if that doesn't happen, I am doing fine, and am happy with my life.

I find myself wishing for a "partner" but only if he's a real friend. My celibacy is comfortable at the moment. It has become apparent to me that our culture has taught most females to sacrifice themselves to their partner's desires and not to defend themselves. I hope I don't fall in that trap again. I find that I satisfy my physical sexual desires better than my husband ever did.

On the other hand, sexual interaction is very important to many of the aging women.

I am 58 and as horny as ever.... The sex urge is still with me, not much different from my earlier years. Maybe I am too physically active and healthy! I can't seem to get it into my head that I am approaching a different time of life.... There is little or no speaking about a situation like mine in books or media. Yet women my age say the same thing: "Where are the men? Men want only younger women. The 'good men' are married or in relationships." ... My request to you is--listen to the voice of the horny women. When we hear each other and gain our dignity solutions will come!

CONCLUSION

Results from the MWHS, some of which have been shared in this article, illustrate that women experience their sexuality as complex and holistic. Thus, it is doubtful that a particular drug or other substance or device that could improve physical functioning (increase libido or vasocongestion) would be the "magic bullet" to transform women's sexuality as they age. In order to understand and enhance women's sexuality throughout their lives, we must listen to their voices, learn from their experiences, and appreciate the importance of context to their sexual expression.

REFERENCES

(1.) R. Basson, J. Berman, et al., "Report on the International Consensus Development Conference on Female Sexual Dysfunction: Definitions and Classifications," Journal of Urology, vol. 163, pp. 888-93; J. Hitt, "The Second Sexual Revolution," The New York Times Magazine, February 20,2000, pp. 34-41, 50, 62, 64, 68-69; J. Leland, The Science of Women and Sex' Newsweek, May 29, 2000, pp. 48-54; P. K. Mansfield, P. B. Koch, and A. M. Voda, "Qualities Midlife Women Desire in Their Sexual Relationships and Their Changing Sexual Response' Psychology of Women Quarterly, vol. 22, pp. 285-303.

(2.) R. Rosen, Major Issues in Contemporary Research in Women's Sexuality. (Roundtable discussion at the Women's Health Research (Symposium, Baltimore, MD.)

(3.) R. Basson, "The Female Sexual Response: A Different Model," Journal of Sex and Marital Therapy, vol. 26, pp. 51-65. S. R. Leiblum, "Definition and Classification of Female Sexual Disorders," International Journal of Impotence Research, vol. 10, pp. S102-S106; R. Rosen, Major Issues in Contemporary Research in Women's Sexuality.

(4.) L. Tiefer, "Historical, Scientific, Clinical and Feminist Criticisms of the Human Sexual Response Cycle:' Annual Review of Sex Research, vol. 2, p. 2.

(5.) R. Basson, "The Female Sexual Response: A Different Model," pp. 51-65; L. Tiefer, "A New View of Women's Sexual Problems: Why New? Why Now?," The Journal of Sex Research, vol. 38, no. 2, pp. 89-96.

(6.) Webster's New World Dictionary of the American Language: College Edition (New York: The World Publishing Company, 2000).

(7.) R. Basson, "The Female Sexual Response: A Different Model," pp. 51-65.

(8.) J. Jordan, Clarity in Connection: Empathic Knowing, Desire and Sexuality, work in progress (Wellesley, MA: Stone Center Working Papers Series, 1987).

(9.) J. Jordan, Clarity in Connection: Empathic Knowing, Desire and Sexuality.

(10.) A. M. Voda and P. K. Mansfield, The Tremin Trust and the Midlife Women I Health Survey: Two Longitudinal Studies of Women's Health and Menopause. (Paper presented at the Society for Menstrual Cycle Research Conference, Montreal, June 1995.); A. M. Voda, J. M. Morgan, et al., "The Tremin Trust Research Program" in N. F. Taylor and D. Taylor, editors, Menstrual Health and illness (New York: Hemisphere Press, 1991), pp. 5-19.

(11.) Midlife Women's Health Survey, 1992, unpublished data.

(12.) P. K. Mansfield, P. B. Koch, et al., "Qualities Midlife Women Desire in Their Sexual Relationships and Their Changing Sexual Response," Psychology of Women Quarterly, vol. 22, pp. 285-303.

(13.) Ibid.

(14.) P. K. Mansfield, P. B. Koch, et al., "Midlife Women's Attributions for Their Sexual Response Changes:' Health Care for Women International, vol. 21, pp. 543-59.

(15.) Ibid.

(16.) P. K. Mansfield, A. Voda, et al., "Predictors of Sexual Response Changes in Heterosexual Midlife Women," Health Values, vol. 19, no. 1, pp. 10-20.

(17.) D. A. Thurau, The Relationship between Body Image and Sexuality among Menopausal Women. (Unpublished master's thesis, Pennsylvania State University, 1996.)

(18.) N. E. Avis, M. A. Stellato, et al., "Is There an Association between Menopause Status and Sexual Functioning?," Menopause, vol. 7, no. 5, pp. 297-309; K. Hawton, D. Gaith, et al., "Sexual Function in a Community Sample of Middle-aged Women with Partners: Effects of Age, Marital, Socioeconomic, Psychiatric, Gynecological, and Menopausal Factors, Archives of Sexual Behavior, vol. 23, no. 4, pp. 375-95.

(19.) N. E. Avis, M. A. Stellato, et al., "Is There an Association between Menopause Status and Sexual Functioning?," pp. 297-309; I. Fooken, "Sexuality in the Later Years--The Impact of Health and Body-image in a Sample of Older Women," Patient Education and Counseling, vol. 23, pp. 227-33; K. Hawton, D. Gaith, et al., "Sexual Function in a Community Sample of Middle-aged Women with Partners: Effects of Age, Marital, Socioeconomic, Psychiatric, Gynecological, and Menopausal Factors," Archives of Sexual Behavior, vol. 23, no. 4, pp. 375-95; B. K. Johnson, "A Correlational Framework for Understanding Sexuality in Women Age 50 and Older," Health Care for Women International, vol. 19, pp. 553-64.

RELATED ARTICLE: HALF OF AMERICANS OVER 60 HAVE SEXUAL RELATIONS AT LEAST ONCE A MONTH

Nearly half of all Americans over the age of 60 have sexual relations at least once a month, and 40 percent would like to have it more often. In addition, many seniors say their sex lives are more emotionally satisfying now than when they were in their forties.

These findings were part of the latest Roper-Starch Inc. survey of 1,300 men and women over the age of 60 conducted by the National Council on the Aging.

"This study underscores the enduring importance of sex among older men and women--even among those who report infrequent sexual activity," said Neal Cutler, director of survey research for the Council. "When older people are not sexually active, it is usually because they lack a partner or because they have a medical condition."

As most people might expect, the survey found that sexual relations taper off with age, with 71 percent of men and 51 percent of women in their sixties having sex once a month or more and 27 percent of men and 18 percent of women in their eighties saying they do. Cutler said women had sex less often in part because women are more likely to be widowed.

Thirty-nine percent of people said they were happy with the amount of sexual relations they currently have--even if it is none--while another 39 percent said they would like to make love more often. Only four percent of the people surveyed said they would like to have sexual relations less frequently. The people who had sex as least once a month said it was important to their relationship.

The survey also found that 74 percent of men and 70 percent of women find their sex lives more emotionally satisfying now that they are older than when they were in their forties. As to whether it is physically better, 43 percent say it is just as good as or better than in their youth, while 43 percent say sex is less satisfying.

"When it comes to knowledge about sex, older people are not necessarily wiser than their children. A third of the respondents believed it was natural to lose interest in sex as they got older," said Cutler.

(Dr. Mansfield is director of the Tremin Trust Research Program on Women's Health. Dr. Koch is assistant director. Dr. Koch is also adjunct professor of human sexuality at Widener University in West Chester, PA.)