In a recent  publication by the American Psychological Association, Dr. Maggie L. Syme from the San Diego State University/University of California San Diego Cancer Center Comprehensive Partnership, is quoted as saying, “Many psychologists and other health-care professionals . . . miss an opportunity to help patients improve their sex lives – simply because they don’t ask.”

As with many other important issues (alcohol/drug abuse, sexual abuse, domestic violence, etc.), if we don’t ask, people often don’t tell, As clinicians, we have been making progress in our assessment protocols for years. Most clinicians do routinely ask about abuse issues as a routine part of intake. But sex and the aging patient? Not so much.

If you are a therapist seeing anyone over the age of 45, it’s important to include questions about their sex life in your standard intake. It is a mistake to assume that the lack of a healthy and regular sex life is merely a predictable and normal symptom of aging. Rather, it may be an indication of other issues that need to be addressed in treatment planning.

Issues That Particularly Impact Sexuality in Seniors:

Belief they are “too old for sex”: In fact, many elderly people are sexually active. If there has been significant decline recently, it may have to do with issues other than age. Seniors may need to be reassured that they are never too old for sex. If they are conflicted or having difficulty with sexual expression, it is important to explore why that may be so.

Self-esteem issues: America and much of the western world is dominated by a youth culture. People who have bought into the idea that sexiness is for the young and beautiful suffer a loss of self esteem as they age. As their bodies decline, so does their sexual desire and/or their belief in their sexual desirability. The task in session is to help these patients come to terms with aging and to explore a new chapter in their sexual relationship with their partner.

Communication issues in couple: For some elderly couples, physical changes have made it from difficult to impossible to maintain their regular, comfortable sexual routines. If talking about sex has never been comfortable, efforts to talk about it now may have resulted in fights or avoidance. Such couples need our help to share information with each other about their changing abilities and desires.

Rigid ideas about what is acceptable: As intercourse becomes less comfortable or possible, many seniors give up on what they consider to be “sex.” Religious and cultural belief systems may also limit what some older clients find acceptable as sexual behavior. It’s important to tread gently. Such strongly held beliefs need to be respected while alternative ways for a couple to be sexually close are explored. They may need help accepting and embracing the idea that touching, stroking, caressing, mutual masturbation and fantasy can also be defined as satisfying and moral sex.

Symptom of mental illness: As acceptability for getting help for personal problems has increased over time, the number of elders coming for first time appointments has also increased. Sometimes they are self-referred. Sometimes a family member has persuaded them – finally – to get some help. Sexual dysfunction may be part of the general clinical picture, not a function of aging. Although it is sometimes a symptom of the dementias, it is also a symptom of the same issues confronted by younger people – depression, bipolar depression or anxiety.

Common medical issues: Cardiovascular disease, diabetes and lower urinary tract issues often contribute to sexual dysfunction. For senior women, there is often difficulty with vaginal dryness. For senior men, the most common problem is erectile dysfunction.  Before designating sexual dissatisfaction as a symptom of psychological distress, it is important to understand the entire medical picture and to collaborate with the client’s primary care doctor.

Medication issues: Be sure to ask for a medication list and to explore whether symptoms, including changes in sexuality, are correlated with taking the drugs. Drugs that contain diphenhydramine (used to treat allergies and anxiety, itching and urinary incontinence), for example, can cause what look like psychological problems and can intrude on people’s interest in sex. Other common side effects in elders include temporary confusion, delirium, memory problems and, if taken long term, cognitive effects.

Lack of a partner: Loss of a partner is inevitable as we age. Someone will die first, leaving the other to manage the multiple losses of widowhood, including the loss of sexual intimacy. Further, here are far more women than men who are without a sexual partner as they age, making it less likely that women will find someone new. But there are many men as well as women who see it as too complicated to try to find a lover or who have tried but been unsuccessful in finding romance. It is not uncommon for such individuals to present with depressive symptoms including resignation, sadness and irritability. It’s important to ask whether the lack of sexual opportunity and sexual expression is part of the problem and to explore ways to get those needs met.

A Charge for Therapists Treating Seniors:

Every therapist owes it to their elderly patients to review their own attitudes toward sex and the senior client. Active sexuality is both possible and desirable throughout the life span. A clinician who doesn’t believe it can’t be helpful.

Questions that tactfully surface the client’s attitudes toward sex at their age and their current state of sexual health and rate of activity need to be part of every intake with senior clients. We need to be sensitive to the possibility that sexual complaints may be an indication of sexual frustration, dysfunction or problems with their intimate partner. If sex is unsatisfying and especially if it is absent, we need to address our patient’s sexual needs in our treatment planning just as surely as we address any other symptom.