Sexuality in Midlife and Beyond

| January 3, 2007

Sexuality in Midlife and Beyond

Sex. The word can evoke a kaleidoscope of emotions. From love, excitement, and tenderness to longing, anxiety, and disappointment the reactions are as varied as sexual experiences themselves. What's more, many people will encounter all these emotions and many others in the course of a sex life spanning several decades.

But what is sex, really? On one level, sex is just another hormone-driven bodily function designed to perpetuate the species. Of course, that narrow view grossly underestimates the complexity of the human sexual response. In addition to the biochemical forces at work, your experiences and expectations help shape your sexuality. Your understanding of yourself as a sexual being, your thoughts about what constitutes a satisfying sexual connection, and your relationship with your partner are key factors in your ability to develop and maintain a fulfilling sex life.

The physical transformations your body undergoes as you age also have a major influence on your sexuality. Declining hormone levels and changes in neurological and circulatory functioning may lead to sexual problems such as erectile dysfunction or vaginal pain. Half of men ages 50 and older report at least occasional erection problems. The figure rises to nearly 60% at age 60 and almost 70% at age 70. In addition, many women contend with issues of vaginal dryness and a lagging libido after they pass menopause (when the ovaries stop producing estrogen).

Such physical changes often mean that the intensity of youthful sex gives way to more subdued responses during middle and later life. But the emotional by-products of maturity increased confidence, better communication skills, and lessened inhibitions can help create a richer, more nuanced, and ultimately satisfying sexual experience. However, many people fail to realize the full potential of later-life sex. By understanding the crucial physical and emotional elements that underlie satisfying sex, you can better navigate problems if they arise. This report will take you through the stages of sexual response and explain how aging affects each. You'll also learn how chronic illnesses, common medications, and emotional issues can influence your sexual capabilities. Finally, you'll find a detailed discussion of various medical treatments, counseling, and self-help techniques to address the most common types of sexual problems.

Understanding sexuality

At this stage in your life, you might feel that you know all there is to know about sex. After all, it's probably been many years since you had your first sexual experience. But if you're like a lot of people, you also possess spotty information and faulty beliefs, some of which may be preventing you from fully enjoying your maturing sexuality. To help you build a solid foundation for a fulfilling sex life, here's a quick overview of human sexuality basics.

How do you define "sex"?

Vaginal intercourse is often given the lofty position as the ultimate sexual event, but clearly the story doesn't end there. Pleasurable activities from casual intimacies such as kissing and caressing to more intense types of physical contact designed to produce orgasm can complement intercourse or stand alone as a means for gratification. The penis and vagina are not the only tools for sexual enjoyment; people can give and receive intense pleasure without any direct genital-to-genital contact. The mouth, breasts, anal area, hands, and other sensitive spots on the skin are significant sources of erotic sensation. Even the friction of bodies rubbing together, clothed or unclothed, can bring sexual pleasure. Sexual activity does not always demand that you have a partner, either. Masturbation, viewing sexually stimulating materials, and creating fantasies all may be avenues for sexual gratification.

Your sexual anatomy

You know these parts of your body are there, even if you don't know them by name. The following descriptions and the accompanying diagrams will acquaint you, part by part, with the structures that make up the male and female genitals.

The phases of sexual response

In the heat of sexual excitement, few people want to bother deciphering the dynamics of their sexual response. However, in cooler moments, acquainting yourself with the physiology of sex can offer clues to help you heighten your pleasure and improve your sexual capabilities.

The process that begins with the first glimmer of desire and culminates in the series of pleasurable rhythmic contractions we know as orgasm can be divided into four distinct phases. Each is characterized by a set of anatomic and physiologic changes. The four phases are as follows:

Desire. Also called lust or libido, desire is the wish for sex. A sight, sound, taste, touch, or smell may spark it. Or it may be ignited by a memory or fantasy. Desire occurs before any physical signs of sexual readiness take place in your body. Desire often leads to arousal and orgasm, but this isn't always the case. Arousal can also lead to desire, and desire can linger on its own indefinitely.

Arousal. During arousal, blood floods into the genitals, triggering the man's penis to stiffen and the woman's labia, clitoris, and upper vagina to swell. Moisture begins seeping from the vaginal lining, creating lubrication. The vagina lengthens, the uterus rises, and the inner and outer lips pull apart, exposing the vaginal opening. The man's testicles pull closer to his body, and his scrotum becomes thicker and flatter. In both sexes, breathing and heart rate accelerate, muscles throughout the body tense, the skin flushes, and nipples become erect.

Orgasm. When muscle tension and genital engorgement peak, a series of rhythmic contractions occurs in the sex organs. The contractions force the congested blood out of the tissues and back into circulation. Along with this comes an abrupt release of muscle tension and a pleasurable sensation. In a man, penile contractions expel semen out of the urethra; this is known as ejaculation. Some women also release fluid during orgasm. While this fluid comes out of the urethra, it's not urine. Glands located in the same area as the G-spot may produce the fluid.

The G-spot

The G-spot, or Grafenberg spot, named after the gynecologist who first identified it, is a mound of super-sensitive spongelike tissue located within the roof of the vagina, just inside the entrance. Proper stimulation of the G-spot can produce intense orgasms. Because of its difficult-to-reach location and the fact that it is most successfully stimulated manually, the G-spot is not routinely activated for most women during vaginal intercourse. While this has led some skeptics to doubt its existence, research has demonstrated that a different sort of tissue does exist in this location.

You must be sexually aroused to be able to locate your G-spot. To find it, try rubbing your finger in a beckoning motion along the roof of your vagina while you're in a squatting or sitting position, or have your partner massage the upper surface of your vagina until you notice a particularly sensitive area. Some women tend to be more sensitive and can find the spot easily, but for others it's difficult. If you can't easily locate it, you shouldn't worry.

During intercourse, many women feel that the G-spot can be most easily stimulated when the man enters from behind. For couples dealing with erection problems, play involving the G-spot can be a positive addition to lovemaking. Oral stimulation of the clitoris combined with manual stimulation of the G-spot can give a woman a highly intense orgasm.

Resolution. Following orgasm, heart rate and blood pressure gradually return to their normal levels. In a man, the penis becomes flaccid; in a woman, sex organs gradually return to their unaroused state. After orgasm, it takes some time before an individual can have another orgasm. For a woman, this stage may pass quickly, allowing her to have multiple orgasms in a short span of time if stimulation continues. A man generally needs to wait longer from several minutes to hours or days, depending on his age before he is able to ejaculate again.

While it's possible to identify these discrete parts of the sexual response cycle, not every sexual encounter needs to progress through all four phases in an orderly manner. Nor must the process necessarily include orgasm. This much is true for both women and men.

The impact of aging

Advancing years leave their mark on the body, mind, and emotions. Some of these changes are for the better, while others are less desirable. Sex is no exception. Many of the physical changes that come with age have noticeable effects on the sex organs and the sexual cycle (see Table 1). Thus, the careful lovemaking of a 70-something couple may bear little resemblance to the lusty pairings of 20-year-olds. This isn't necessarily a bad thing. Greater experience, fewer inhibitions, and a deeper understanding of your needs and those of your partner can more than compensate for the consequences of aging, such as slower arousal, softer erections, reduced vaginal lubrication, and less intense orgasms. And these physical changes can provide an impetus for developing a new and satisfying style of lovemaking one that's based more on extended foreplay and less on intercourse and orgasm.

Table 1: Possible age-related sexual changes in women and men
	Women	Men
Physical changes	Decreased blood flow to the genitals. Lower levels of estrogen and testosterone. Thinning of the vaginal lining. Loss of vaginal elasticity and muscle tone.	Decreased testosterone. Reduced blood flow to the penis. Less sensitivity in the penis.
Desire	Decreased libido. Fewer sexual thoughts and fantasies.	Decreased libido. Fewer sexual thoughts and fantasies.
Arousal	Slower arousal. Reduced vaginal lubrication and less expansion of the vagina during arousal. Less blood congestion in the clitoris and lower vagina. Diminished clitoral sensitivity.	Greater difficulty achieving an erection, maintaining an erection, or both. Erections aren't as rigid.
Orgasm	Delayed or absent orgasm. Less intense orgasms. Fewer and sometimes painful uterine contractions.	Longer time required to reach orgasm. Smaller volume of semen and less forceful ejaculation. Less intense orgasms.
Resolution	Body returns more rapidly to an unaroused state.	Body returns more rapidly to an unaroused state. More time is needed between erections.

What is sexual dysfunction?

Sexual dysfunction can be defined as any aspect of your sexual response that causes you or your partner dissatisfaction or distress. The focus here is not on the problem itself, but on the fact that the condition is troubling to the people involved. For example, if both members of a couple are content to live without sexual activity, then such conditions as erectile dysfunction or vaginal dryness would not be considered sexual dysfunction. Likewise, a woman who is not involved in a relationship may not be concerned by her low libido. On the other hand, if she finds a partner who has a more active sex drive, her lack of interest may become a problem.

Experts usually divide types of sexual dysfunction into male and female issues. Under these headings, they define more specific problems based loosely on three of the four phases of sexual response: desire, arousal, and orgasm. Despite these distinctions, sexual problems are often complex and incorporate elements from more than one category.

Attitudes about sexuality and aging

shouldn't, can't, wouldn't want to The oldest members of the baby boom generation were in their 20s during the heyday of the 1960s sexual revolution, fostered in part by the advent of the birth control pill. During that time, sexual attitudes and practices shifted dramatically. Now these boomers are once again transforming the sexual landscape, challenging views on sexuality and aging. As a result, the once widespread myths that people in their 60s and beyond and have sex are fading away.

There is greater recognition now that many older adults are physically and mentally vital. This has inspired the saying "60 is the new 40." Examples of vigorous older adults are easy to find. Former president George H.W. Bush went skydiving to celebrate his 80th birthday, and John Glenn returned to space at age 77. It makes sense that this trend toward later-life vitality reaches into the bedroom, too.

Middle-aged and older adults no longer accept such myths as "Sex is only for young people" and "Sex isn't important to older adults." A study, "Sexuality at Midlife and Beyond," conducted by AARP, illustrates this. These are some of the findings:

Five out of six of the respondents disagreed with the statement that "Sex is only for younger people."
Six out of 10 people stated that sexual activity was a crucial part of a good relationship.
Only 10% of adults reported that they don't particularly enjoy sex, and just 12% agreed that they would be quite happy never having sex again.

The 2004 AARP study is a follow-up to a study that was conducted five years earlier. The 2004 poll of 1,682 men and women turned up some interesting changes in sexual attitudes and behaviors. One of the most significant is the growing number of adults seeking information about sexuality and treatment for sexual problems. In 1999, half of the respondents had sought information about sex; in 2004, that number rose to 62%.

Over all, the number of people seeking help for a sex problem crept up from 14% to 18%, but the jump was more significant for men alone. The proportion of men who said they have tried medications and other treatments to improve sexual functioning more than doubled, going from 10% to 22%. Viagra was by far the most commonly used treatment; in fact, the percentage of people who've tried Viagra nearly matched that of all the other treatments (such as hormone injections, pills and patches, herbs, Levitra, Cialis, and vacuum pumps or other devices) combined.

Many of those who tried medication or other treatments for sexual problems reported that the therapies increased their enjoyment or satisfaction with sex. Their partners agreed. Over all, 68% of men and 55% of women who sought treatment reported greater sexual satisfaction. Among those whose partners used a drug or other treatment for sexual problems, 56% of the women and 64% of the men reported that they enjoyed sex more as a result.

The AARP survey examined a variety of other sexual attitudes and behaviors, from the frequency of sexual activity to factors affecting sexual satisfaction. For more on these findings, see "By the numbers: Statistics on sexuality and sexual satisfaction."

By the numbers: Statistics on sexuality and sexual satisfaction In 2004, AARP polled 1,682 adults ages 45 and older about the role sex played in their lives. The findings paint a detailed picture of sexuality at midlife and later. The importance of sex Over all, two-thirds of the men (66%) and about half of the women (48%) responding felt that a satisfying sex life was important to their quality of life. An even higher percentage (90% of men and 85% of women) said that a good relationship with their spouse or partner played a key role in their happiness. Frequency of sexual activity Of individuals with partners, 49% reported having intercourse once a week or more in the past six months. About 59% of men and 54% of women in the youngest age bracket surveyed (4549) had intercourse at least once a week. Over age 70, the number dropped to 34%. Some other sexual activities were more prevalent among those with partners: 88% kissed or hugged at least once a week, while 72% engaged in sexual touching or caressing that frequently. As expected, the numbers were lower for study participants as a group (see table below), since a portion of them did not have partners. Men tended to think about sex and feel sexual desire more frequently than women. While rates of intercourse were similar for both sexes, more men than women reported engaging in sexual touching. Self-stimulation on a regular basis was also about four times higher among men. Factors affecting sexual satisfaction Not surprisingly, one of the major factors associated with respondents' satisfaction was the availability of a partner. In the 4549 age group, roughly four out of five individuals had partners; by comparison, only one-third of women over 70 had a partner. Declining health also appeared to have an effect on sexual activity and satisfaction. On a list of features that might improve their sexual satisfaction, respondents ranked better health for themselves or their partners at the top.
Other statistics from the survey	Men	Women
A good relationship with a spouse or partner is important to quality of life.	90%	85%
My partner is physically attractive.	58%	52%
A satisfying sexual relationship is important to my overall quality of life.	66%	48%
Sexual activity is a pleasurable but not a necessary part of a good relationship.	45%	51%
Had sexual intercourse at least once a week during the past six months.	41%	31%
Engaged in kissing or hugging at least once a week during the past six months.	76%	62%
Am satisfied with my sex life.	52%	49%
Better health for me would improve my sex life.	31%	19%
Better health for my partner would improve my sex life.	23%	20%
Have taken medication or used other treatments to improve sexual functioning.	22%	7%
Sex becomes less important to people as they age.	42%	42%

Emotional and social issues

The brain is the body's most important sex organ." This oft-repeated phrase bears more than a little truth. While the initial prerequisites for sexual activity are physiological functional sex organs, adequate hormone levels, and freedom from health conditions that interfere with the body's ability to respond to erotic cues these elements don't guarantee sexual satisfaction. A number of other factors, combined with naturally occurring physical changes, can make you more vulnerable to sexual problems.

Lack of a partner

It may seem obvious that not having a partner is an impediment to an active sex life, but it's an important issue for older people. By age 65, many people find themselves alone, through either divorce or widowhood.

According to the AARP sexuality survey, 64% of men with partners and 62% of women with partners are primarily satisfied with their sex lives. This is in sharp contrast to the small proportion of those without partners (19% of men and 28% of women) who are pleased with their sex lives.

The partner gap is a particular problem for American women because their average life span (80 years) is about five years longer than that of men. Because American women marry men who are on average three years older, that can mean even more time alone. Should a woman want to remarry, her chance of finding a new mate in her age bracket dwindles yearly; there is an average of only 7 men for every 10 women ages 65 and above.

Finally, starting a new sexual relationship after divorce or the death of a spouse can present its own dilemmas. People often fear that they will not become aroused or be able to have an orgasm with a different partner. They also may be self-conscious about baring their body in front of someone new. Because a new relationship may come along months or years after their last sexual relationship, some individuals feel anxious that they have "forgotten how to have sex" or that "the equipment doesn't work anymore." For those who have lost a much-loved spouse, feelings of guilt or disloyalty at starting a new relationship can be overwhelming.

Relationship issues

Tension and emotional distance in a relationship can be deadly to a couple's sex life. In many cases, conflict is at the root of a sexual problem. Other times, a sexual issue strains a couple's ability to get along. The following issues are often connected to sexual problems.

The Viagra revolution

In 1998, sildenafil (Viagra) burst onto the scene. Within days, male sexuality was making headlines, and within weeks, sales of the "little blue pill" were making history. The success of Viagra spawned the development of two similar drugs: vardenafil (Levitra) and tadalafil (Cialis). Now, millions of couples have seen firsthand what these drugs can and can't do.

In many cases, these medications are the answer to a prayer for men who have been unable to have an erection. But these pills offer no help in untangling the emotional and relationship pressures that frequently accompany erectile dysfunction.

For one thing, they work only if the man is feeling sexual desire for his partner. If emotional issues are impinging on libido, the pills won't help. For example, a man may feel so embarrassed by being unable to get an erection that he is no longer willing to attempt sexual activity, and his partner may mistakenly believe that he is no longer attracted to her. When Viagra, Levitra, or Cialis enters the picture, the woman may find it hard to let go of past feelings of rejection. She may mistakenly assume that her husband's newfound erections are merely a chemical phenomenon, not an outgrowth of sexual attraction to her. In these cases, sex therapy is helpful.

When intercourse is suddenly a possibility again, relationship issues can sprout up or resurface. For example, dramatic differences in libido sometimes emerge. Also, a woman can develop problems related to vaginal dryness and atrophy (see "Vaginal pain") if she hasn't had sex in a long time. She may need to undergo a few weeks of therapy using medication or dilators before she can comfortably resume intercourse.

The bottom line is that couples should try to regard pills for erectile dysfunction as an opportunity to become erotic again, while realizing that they are neither a mandate to have intercourse nor a panacea for every problem in the bedroom.

Performance anxiety

Defined as an overwhelming concern about sexual performance that obscures pleasure and leads to sexual dysfunction, performance anxiety is a particularly insidious issue affecting aging couples. Performance anxiety becomes a problem for both men and women as they move into their 50s.

In men, it's the most common psychological contributor to erectile dysfunction. Here's how the problem often develops. The natural effects of aging dictate that a man needs more time and direct penile stimulation for an erection. Medications and cardiovascular disease may also contribute to erection difficulties. If a man continues to expect the instantaneous rock-hard erections of his 20s, he may equate this change in his physical response with the end of his virility. Once he makes this erroneous leap, the problem snowballs. After a few incidences of erection failure, embarrassment and feelings of defeat leave him unwilling to try again. He may withdraw from all forms of physical intimacy to avoid having to perform. In turn, his partner feels rejected and fears that she's no longer attractive enough to sexually excite him. She may also suspect him of having an affair.

If this happens, the woman may shy away from touching her partner sexually out of fear that another failure will occur. Paradoxically, her reticence denies the man just the type of direct stimulation that he needs to achieve an erection. The result is that an addressable physical issue becomes a morass of anger, resentment, and frustration.

Women experience performance anxiety in different ways. Performance anxiety is common in women who have experienced pain during sex (dyspareunia) in the past. They may be worried that sex will be uncomfortable again, and this anxiety can decrease lubrication. In turn, this makes sex painful, which heightens their anxiety and further interferes with lubrication. Ultimately, some women decide to avoid sex entirely.

The frank discussion of sexuality that has become commonplace in women's magazines and on daytime television can also contribute to performance anxiety. This openness has had the unintended consequence of making some women worry that they do not respond quickly or intensely enough to be considered a "good lover."

Body image and self-esteem

Gravity is not kind to your body as you age. Nor is childbirth, a fatty diet, lack of exercise, or the hormone declines that lead to muscle loss, loose skin, and thinning hair. What does this have to do with your sex life? It can have everything to do with it if you let it. Worry about having your partner see your sagging breasts or potbelly can discourage you from having sex, or you may demand that sex take place only under the covers, with the lights out, while you're wearing a T-shirt. Needless to say, these conditions don't leave much room for inspired lovemaking. Often, a preoccupation with your appearance while making love will prevent you from fully enjoying sex.

Relationship conflicts can ensue. When one partner needs constant reassurance about his or her attractiveness and becomes overly sensitive to perceived criticism, it can foster mutual resentment.

By shifting your focus away from your perceived flaws to your attributes, you can boost your self-esteem and establish your own standards for attractiveness. Think back on what it was that made you attractive in your younger years. Was it your soulful brown eyes, your crooked smile, or maybe your infectious laugh? Chances are, those qualities are still as appealing as ever.

Also, try directing your attention to the experience of giving and receiving pleasure during sex. This can help you find the confidence to give yourself over to the experience. Great sex is often the outgrowth of a deep emotional connection something that's not guaranteed by having a perfect body.

A negative self-image isn't always rooted in your appearance. Career setbacks or other disappointments can lead to feelings of failure and depression, both of which sap desire. For men, episodes of impotence can undercut confidence in their manhood. No matter what its cause, a poor self-image can take a toll on your sex life. When performance anxiety develops as a result, it can spark a downward spiral of repeated sexual failure and diminishing self-esteem. Correcting this problem demands serious attention to its origin.

Expectations and past experiences

Your sexuality is a natural drive that's with you from birth, but your family, your culture, and your religious background shape your attitudes toward sex. As you become an adult, your own experiences further influence your sexuality. The result for many is a healthy enjoyment of sex, but others may have more mixed feelings.

For example, women particularly those who came of age before the so-called sexual revolution in the '60s may cling to the notion that it is improper for "nice girls" to initiate and enjoy sex too enthusiastically. This belief can be damaging for both partners. The woman may feel uncomfortable seeking pleasure, and her partner may interpret this lack of enthusiasm as a reflection of her feelings about him.

Inexperience and embarrassment over discussing sexual matters may hamper people from fully expressing themselves sexually. For example, intercourse alone does not give many women the kind of stimulation they need for fulfilling sex, and uneasiness about discussing the problem prevents some couples from developing techniques that could offer greater pleasure. Compounding the problem, childhood taboos against masturbation may prevent a woman from discovering the means to her sexual pleasure, so she's unable to direct her partner in this regard. A woman may find it easier to forgo her own pleasure than to confront these matters. She may ultimately resort to faking orgasms rather than risk asking for a different approach to lovemaking. When this pattern exists for years, revealing the truth would mean admitting to a longstanding deception, which could shake the relationship.

Alternately, a man may feel his self-worth depends on his ability to please his partner. His focus during sex, therefore, is on performing rather than succumbing to pleasure. If his partner doesn't immediately respond to his efforts, feelings of inadequacy can pervade the relationship, eroding the couple's bond and leading to performance anxiety.

During the early years of a couple's relationship, such missed connections are often masked by priorities outside the bedroom, such as building a marriage, raising a family, and launching a career. However, midlife may be a turning point. Upon reaching menopause, the long-unsatisfied woman might greet the physical changes in her body as a sign that her sexual "duties" are fulfilled. If her husband is still interested in sex, a conflict is likely to erupt.

A much more hopeful scenario is also possible. Midlife and later may be a time when a woman's sexuality blossoms. Women often gain confidence as they mature, and they may be more willing to ask for what they want sexually. Menopause means that women no longer have to worry about pregnancy (or birth control). Often, children are grown and family responsibilities have eased, allowing a couple to engage in more relaxed and spontaneous lovemaking. In addition, the changes a man is experiencing during these years, such as slower erections and longer time before ejaculation, lend themselves to the kind of pleasurable play that a woman may have been missing out on before. For a couple wishing to embark on the more positive course, the key is to begin to unravel negative patterns. To do this, you must open up a dialogue.

Stress and lifestyle issues

Stress and fatigue are major libido sappers. During midlife, stress can hit from any direction. Challenging teenagers, financial worries, aging parents, concern about your health or that of a loved one, and career woes are common. With so many demands on your time and attention, you and your partner may neglect to nurture your relationship, which can cause your sexual connection to fray.

Sheer lack of time is often a major factor. The physical changes in sexual response that occur in both men and women as they age mean that it will take you and your partner more time to become aroused and reach orgasm than it did in your younger years. You may find it hard to squeeze an extended lovemaking session into an already packed day. If a couple typically waits until bedtime to have sex, exhaustion also can become an obstacle.

Stress has a particularly deleterious effect on libido, especially in women. Whereas men can sometimes use sex to relax, women more often need to be relaxed in order to enjoy sex. This mismatch can create conflict for a couple.

Sexual issues brought on solely by stress and fatigue often can be remedied simply by taking a short vacation. If you and your partner are able to resume pleasurable lovemaking in a pressure-free environment, you'll be reassured that the underpinnings of your sexual relationship are sound.

Midlife and after is also a time when profound lifestyle changes take place. Events such as retirement and children leaving home can upset decades-long patterns in a couple's life. Many couples go through a period of adjustment when they retire. For example, if one person is used to being in the house alone much of the time, his or her feeling of control over the domain can be threatened by the partner's constant presence.

One bonus is that retirement or changes in working habits may allow you and your partner the opportunity to engage in leisurely lovemaking something you may have lacked for many years. One danger, however, is that couples who begin spending a lot of time together may stop making an effort to include romance in their relationship.

Chronic illness is a major cause of sexual difficulties. People who are ill may find that a condition or its treatment causes sexual difficulties, while healthy partners may worry that sexual activity will make their loved one's condition worse. The fatigue and stress of the caretaker role may also dampen desire. In addition, sexual interest may wane for both partners if their caretaker-patient relationship begins to feel too much like that of a parent and child. During this time, many people also experience the loss of someone close. Grieving may make it difficult to enjoy anything pleasurable, including sex.

Sexuality and health problems

Long-term medical conditions compound the sexual issues that men and women already face during the natural aging process. Heart disease, diabetes, cancer, and arthritis are just some of the illnesses that can have a serious, lasting impact on your sexuality. Treatments can also alter sexual functioning. What's more, the emotional effects of an illness often weigh as heavily as the physical ones. One or both members of the couple may experience depression, which is a major contributor to sexual problems.

As you might expect, the AARP sexuality survey found that healthy individuals are more likely to engage in sexual activity. The survey found that 44% of people who characterized their health as excellent or very good had intercourse at least once a week. But as health status declined, so did sexual activity. About 33% of the people with good health and just 20% of those with fair or poor health had intercourse this frequently. And many of the respondents reported that better health for either themselves or their partner would improve their sex lives.

When you're first confronted with an illness, things may look bleak. But many people are able to resume a satisfying sex life after an initial adjustment phase. The first step to overcoming these challenges is to investigate the potential effects of the disease and treatment on your sex life. This section provides an overview of some common conditions and how they affect sexuality in later life. But it is also important to discuss these issues with a doctor.

Keep in mind, too, that there are many ways to maintain physical intimacy. Some couples find that they can have a satisfying relationship without intercourse. However, even in the absence of sexual contact, preserving other forms of affection such as hand-holding and cuddling is crucial for maintaining a healthy, positive relationship.

A wide variety of illnesses can cause or exacerbate sexual problems, but given the scope of this report, it isn't possible to include information about all of them. Here is a closer look at some of the most common culprits.

Fast fact

Roughly 13 million Americans have coronary artery disease, the most common form of heart disease, and 65 million Americans have high blood pressure.

Heart disease

Your heart is linked to your sexual organs, both physically and metaphorically. When you have chest pain or a heart attack, it's usually because fatty deposits have narrowed your arteries (a condition called atherosclerosis) and the heart tissue is not receiving enough blood. When atherosclerosis strikes the coronary arteries, it's a good bet that other vessels in your body have met the same fate including those that serve your genitals. Because the penis needs a rapid influx of blood to achieve an erection, it's easy to see why vascular disease is the leading cause of erectile dysfunction. Atherosclerosis may also cause female arousal difficulties by preventing sufficient amounts of blood from reaching sex organs. Engorgement of the blood vessels of the vagina is needed for adequate lubrication and arousal.

Journal of the American Medical Association After a heart attack, many people fear that the exertion of sex will bring on another attack. In reality, the cardiovascular demands of sex are relatively mild about the equivalent of walking briskly up two flights of stairs. A study in the concluded that chances are only one in a million that a man who had previously had a heart attack would have another during or immediately following sex. Those who engage in regular physical activity are at the lowest risk.

Although your doctor will give you specific instructions when you leave the hospital, most people should be ready to resume normal sexual activity within four weeks after a heart attack. If you're recovering from bypass surgery, you may have to wait six weeks before having sex, and you may need to avoid positions that could strain your incision.

Likewise, chronic stable angina should not be a barrier to sex if you're accustomed to doing other things that require the same level of exertion. Some cautions apply, though. You cannot use Viagra, Levitra, or Cialis if you're taking a medication that contains nitrates (such as nitroglycerine); the interaction of these drugs can cause life-threatening drops in blood pressure. People with unstable angina may need to abstain from sexual activity altogether. If you have this condition, consult your doctor before engaging in sex.

Tips for resuming sex after a heart attack

Here's some advice for successful lovemaking after having a heart attack.

Find a time when you are both rested and relaxed. This may be in the morning or after a nap.
Choose a place that's comfortable and familiar, where you won't be interrupted.
Take any medications your doctor may have prescribed for you to use before sex.
Don't feel that you need to have intercourse right away. Cuddling and caressing may be a more comfortable way to start.
Talk to your partner about any concerns you have. Be understanding of the emotions that both of you may be experiencing.

High blood pressure

Hypertension (high blood pressure), another form of vascular disease, also contributes to sexual dysfunction. It changes circulatory patterns in the body and damages the inner lining of arteries (the endothelium), both of which may decrease blood flow to the penis and vagina. Moreover, many popular blood pressure medications can cause erectile difficulties. In fact, sexual problems are a main reason why people stop taking drugs that lower blood pressure. But doing so can be quite dangerous, given that high blood pressure is a leading cause of stroke and also plays a huge role in the physiologic changes that underlie heart attacks and heart failure.

Problems attributed to high blood pressure or drug therapy for it include impotence and ejaculation problems in men, painful or uncomfortable intercourse and difficulty having an orgasm in women, and lack of desire in both.

In theory, controlling high blood pressure should help preserve or even improve sexual function. In practice, it doesn't, at least not according to large studies. It's possible, though, that improvements in some people are offset by sexual side effects of drug therapy in others.

Sexual side effects have been ascribed to virtually all classes of drugs used to control blood pressure (see Table 3). In most studies, it has been almost impossible to tell if the problem stemmed from drug therapy or high blood pressure itself. A few studies have suggested that different drug classes have different effects on sexual function, and one class angiotensin-receptor blockers may even improve it.

If you think a blood pressure drug is putting a kink in your sex life, talk to your doctor. Many different drugs are used to treat blood pressure, and with your doctor's help you may find a better alternative.

Diabetes

Unchecked, diabetes can be devastating to sexual function. About 35%50% of men with diabetes experience erectile dysfunction. The disease contributes to erectile problems in at least two ways: It can impair the nerves that instruct the arteries of the penis to dilate, and it can restrict blood flow to the penis by damaging the blood vessels. People with diabetes often have high blood pressure and high levels of cholesterol and other fats in the blood all of which may further damage blood vessels and impede blood flow.

Among people with diabetes, erectile dysfunction usually develops gradually over a period of months or years. At first, the erection may not be as rigid as it had been or the erection can't be sustained. Sometimes, erectile dysfunction is the first sign that a man has diabetes.

Carefully controlling blood sugar can help prevent the vascular and neurological complications that contribute to sexual problems. But even with proper treatment, men who have diabetes are three times as likely as other men to develop erectile dysfunction.

For women, the sexual effects of diabetes are more subtle, but they can be equally distressing. Diabetes can damage blood vessels and nerves, interfering with clitoral sensation and vaginal lubrication and causing difficulties with arousal and orgasm. The disease may also cause low libido. In addition, high blood sugar contributes to frequent yeast and bladder infections, which can make sex uncomfortable or impractical for long stretches during treatment.

Many men with diabetes can take pills for erectile dysfunction, although these drugs are less effective for diabetes-related erectile dysfunction than for other causes. Studies have found that while approximately 70% of men with erectile dysfunction from other causes responded well to Viagra, only 57% of diabetic men with erectile dysfunction reported improvement. Other treatments including drugs delivered by injection or suppository, vacuum erection devices, and penile prostheses appear to be more helpful for diabetic men.

Arthritis

The pain, stiffness, and flexibility problems common with arthritis often interfere with physical intimacy, especially when the hips, knees, or spine are involved. However, even people with severe arthritis can enjoy an active sex life.

A flexible attitude often compensates quite well for having a less-than-flexible body. Try different positions to find the one that is most comfortable for intercourse. For example, people with arthritis in the hips, knees, or spine often find sex most comfortable when both parties lie on their sides. Also consider expanding your sexual repertoire to include other mutually gratifying sexual activities besides intercourse.

Rescheduling sexual activity may also help. For example, if pain and fatigue are worse in the morning, plan on a romantic afternoon instead.

Many people find that taking a painkiller or a long, warm shower an hour before sex lessens muscle and joint stiffness. You can also place pillows under your joints to relieve pain. Special angled wedges or cushions that are designed to make intercourse more comfortable are available and can be easily found on the Internet. Another option is to replace your regular bed with a waterbed.

Cancer

The physical and psychological ramifications of cancer can deal a serious blow to sexual functioning. Cancer's effects are both direct and indirect. The disease itself can cause fatigue and pain, and the diagnosis may also engender fear, depression, guilt, stress, and poor self-image.

Cancer treatments often produce another set of problems. Nearly half of the women who undergo treatment for breast or gynecologic cancer have long-term sexual problems. For men, prostate cancer treatment causes erectile dysfunction about 85% of the time; however, these effects vary based upon the type of treatment the man chooses. His chances of returning to sexual functioning also depend heavily on his age, his health habits, and the priority he places on sexual activity. A closer look at the impact of common cancer treatments follows.

Depression

A complicated relationship exists between depression and sexuality. Depression can be both the cause and the result of sexual problems. For example, loss of desire can be a symptom of depression. Or it may appear first and provoke depression. A lack of interest in sex can lead to relationship problems, feelings of inadequacy, and other emotional issues, which in turn can result in depression. Libido isn't the only aspect of your sexuality affected by depression. Women may be less likely to have orgasms when they are depressed. And in one study, depressed men were twice as likely to experience erectile dysfunction as those who weren't depressed.

Two studies suggest that hormones may be one source of the connection between depression and sex. Data from the Harvard Study of Moods and Cycles, published in 2003, revealed that women with a history of depression were 20% more likely to enter perimenopause sooner than their nondepressed counterparts. For the most severely depressed women, early onset of perimenopause was twice as likely. Another study described a similar effect in men: The depressed men secreted lower levels of testosterone than those without depression.

Psychiatric Annals Further complicating the issue are the sexual side effects of many frequently prescribed antidepressant drugs. Medications called selective serotonin reuptake inhibitors (SSRIs) which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) can dampen desire and make it difficult to become aroused, sustain arousal, and achieve orgasm. Antidepressants can also cause vaginal dryness. An article in suggests that as many as half of all people taking SSRIs experience some sexual problems.

But you don't need to sacrifice your sex life in order to treat depression. Some newer antidepressants including bupropion (Wellbutrin) and mirtazapine (Remeron) are less likely to cause sexual problems. There are reports that bupropion may boost sexual drive and arousal, as well as the intensity or duration of an orgasm. Older medications, known as tricyclic antidepressants and monoamine oxidase inhibitors, don't usually cause sexual problems, but they have other potentially dangerous side effects. Your doctor can help you sort out which medication is right for you.

If you're taking an SSRI, other approaches may help offset or eliminate sexual problems:

Lowering the dose. Sexual side effects may subside at a lower, although still therapeutic, dose.
Taking a drug holiday. Depending on how long the antidepressant medication usually remains in your body, you might stop taking it for a few days before a weekend, if that's when you hope to have sex. This is hardly spontaneous, but it can work if you carefully follow your doctor's directions about how to stop and resume your medication. However, there is always a chance that this might cause a relapse.
Journal of the American Medical Association Adding a drug. In both men and women, Viagra may counteract the negative sexual effects of SSRIs. A study published in the in 2003 found significant improvement in erectile function, arousal, ejaculation, orgasm, and overall satisfaction among men who took Viagra to counteract sexual problems stemming from SSRI use. Adding bupropion to your treatment may also offset the sexual side effects of SSRIs.

Medications

There are hundreds of potentially lifesaving medications available today to treat heart disease, depression, and a host of other problems. The downside is that some of these drugs can impair your sexual enjoyment. Table 3 lists commonly used medications that have been shown to have sexual side effects in some people. A word of caution: If you think a drug you're taking is hampering your sexual functioning, don't stop taking it without talking to your doctor first. He or she may be able to adjust your dosage or switch you to a drug that you tolerate better.

TABLE 3: Medications that can cause sexual problems
Type of medication	Uses	Some examples: Generic name (brand name)	Possible sexual side effects
ACE inhibitors	Heart disease	captopril (Capoten), enalapril (Vasotec), ramipril (Altace)	Low libido, erectile dysfunction
Antidepressants	Depression	citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)	Low libido, erectile dysfunction, female arousal problems, orgasm difficulties
Antifungals	Fungal infections	amphotericin B lipid complex injection (Abelcet), itraconazole (Sporanox), ketoconazole (Nizoral)	Erectile dysfunction
Antihistamines	Allergies	cyproheptadine (Periactin), diphenhydramine (Benadryl), hydroxyzine (Atarax)	Vaginal dryness, erectile dysfunction
Anti-ulcer drugs	Acid reflux, heartburn, ulcers	cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac)	Low libido, erectile dysfunction
Beta blockers	Heart disease, high blood pressure	penbutolol (Levatol), propranolol (Inderal), timolol (Blocadren)	Low libido, erectile dysfunction, female arousal problems, orgasm difficulties
Calcium-channel blockers	Heart disease	diltiazem (Cardizem), nifedipine (Procardia), verapamil (Verelan)	Erectile dysfunction
Cholesterol-lowering drugs	High blood lipids	lovastatin (Mevacor), niacin, simvastatin (Zocor)	Erectile dysfunction
Diuretics	High blood pressure, fluid retention	chlorothiazide (Diuril), chlorthalidone (Thalitone), spironolactone (Aldactone)	Erectile dysfunction, female arousal problems, orgasm difficulties
Nitrates	Chest pain	isosorbide dinitrate (Isordil), isosorbide mononitrate (Imdur, Ismo)	Erectile dysfunction
Tranquilizers	Anxiety	chlordiazepoxide (Librium), diazepam (Valium), thioridazine (Mellaril)	Low libido, erectile dysfunction, female arousal problems
Miscellaneous	Various conditions	anti-androgens, anticholinergics, some anticancer drugs, estrogens, finasteride (Proscar and Propecia)	Erectile dysfunction

Treating common sexual problems

Journal of the American Medical Association, Unlike arthritis or high blood pressure, sexual problems aren't something most people feel comfortable discussing with friends and neighbors. Because of this tendency to suffer silently, you may be surprised by how many people contend with this issue: According to a study in the 43% of women and 31% of men under age 60 have some type of sexual dysfunction. And the numbers rise with age. The Massachusetts Male Aging Study found that by age 65, two-thirds of men have some degree of erectile dysfunction and one-sixth are completely impotent. In sharp contrast, of the adults who responded to the AARP sex survey, relatively few just 28% of men and 10% of women had ever sought medical advice for sexual problems.

Although many adults place a high value on a healthy sex life (see "Attitudes about sexuality and aging"), most don't know where to turn when sexual problems creep up. Some assume that the loss of sexuality is an inevitable, although regrettable, part of aging and resign themselves to a sexless existence. Others are too overcome by embarrassment to seek advice, but this may only intensify feelings of frustration, anger, and inadequacy.

The popularization of Viagra in the late 1990s went a long way toward normalizing the issue of erectile dysfunction. Countless men sought help as a result. What's less well known is that many other sexual problems can also be treated effectively in men and women, often without medication.

This section describes the major classifications of sexual problems and provides an overview of treatment options. Keep in mind that it's not unusual for a person to experience more than one kind of sexual dysfunction, and that therapies may overlap. Treatment often combines medication with sex therapy and self-help techniques.

Erectile dysfunction

There's been a revolution in the treatment of erectile dysfunction. As a result, a problem that was once spoken of only in whispers is now a topic for daytime TV. Although it still isn't easy to acknowledge intimate problems, the openness allows men with this condition to see that they are not alone.

Because many men are reluctant to acknowledge erection difficulties, it is difficult to determine just how common the problem is. However, the American Urological Association estimates that erectile dysfunction affects 25 million American men. While it can strike any man who is old enough to have an erection, erectile dysfunction becomes more common with age. One study found that approximately 40% of 40-year-old men, 50% of 50-year-old men, and 67% of 70-year-old men had some degree of erectile dysfunction.

Don't let these numbers fool you into thinking that erectile dysfunction is an inevitable part of aging. It isn't. Although age-related changes such as lower testosterone levels, decreased blood flow to the genitals, slower nerve function, less elastic erectile tissue, and increased stress all play a part, even these factors don't fully explain all the numbers. The problem often results from an illness that becomes more prevalent with age such as cardiovascular disease or diabetes or its treatment. Many of these conditions can be prevented with good health habits such as following a healthy diet, exercising regularly, maintaining a normal weight, and not smoking.

Low libido

Diminished sex drive is the most common and the most elusive sexual dysfunction. According to a 1994 landmark study of sexuality in America conducted by University of Chicago researchers, 33% of women and 16% of men reported they had gone through periods of several months when they had no interest in sex. A particularly challenging aspect of the problem is that it often exists along with one or more other sexual dysfunctions. For example, a woman who experiences painful intercourse will understandably shy away from sexual activity.

Female sexual arousal disorder

When a woman becomes aroused through thoughts and fantasies, physical stimulation, or both, blood flows to her pelvic region, causing her genital tissues to swell and her vagina to moisten (see "The phases of sexual response"). These changes indicate her physical readiness for sexual intercourse. With female sexual arousal disorder, however, the sequence breaks down, and the woman's body doesn't produce the necessary response.

Because for years this problem was considered evidence of either a psychological issue or a hormone imbalance, treatment was either counseling or estrogen therapy. Then medical researchers examined another possibility. Since blood flow plays a crucial role in arousal, researchers speculated that blood flow problems might produce arousal disorders in women, much the same way that diminished blood flow can cause erectile dysfunction in men. The search for a female Viagra was on.

However, researchers soon learned that arousal is more complex in women than in men. Pfizer, the maker of Viagra, tested the drug in women and found that it did alter blood flow to the genitals, but it did not improve libido in most women. Still, researchers are looking at other drugs and products aimed at increasing genital blood flow in the hopes that these will be effective treatments for female arousal problems.

Vaginal pain (dyspareunia)

A particularly distressing sexual problem for women is chronic vaginal pain. About one in five American women may experience this problem at some point in her life. Like back pain or headache, dyspareunia is an umbrella term encompassing a variety of unpleasant sensations that have psychological or physical causes. The pain can be diffuse and intermittent, it may appear when pressure is applied to certain areas, or it may emerge only when a woman is attempting sexual intercourse. A woman who experiences painful intercourse may become reluctant or unable to have sex, which can strain an intimate relationship.

Orgasm difficulties

Few aspects of human sexuality have incurred the intense debate that has surrounded orgasm. As scientists struggle to quantify this holy grail of sexual experience, certain questions come up repeatedly: Are orgasms the same for women and men? Is an orgasm primarily a psychological or physiological experience? Do women have more than one kind of orgasm, and which type is better? The frenzy of speculation on these points will no doubt continue, but the highly individual and subjective nature of orgasms forces another important question: When does an orgasm difficulty become a dysfunction? As with other sexual problems, an orgasm that is premature, delayed, or absent warrants special attention only when it causes you or your partner distress.

The role of sex therapy

Sexual problems are nearly always intertwined with psychological issues. As a result, solving the physical problem (if one is present) is only half the battle. If sexual issues persist for any length of time, performance anxiety, anger, frustration, low self-esteem, lack of physical affection between you and your partner, and a sense of hopelessness about the problem can further debilitate your sex life. So can a tendency to blame yourself or your partner for the problem. Most people need help repairing the emotional distance created by the problem before they can regain a healthy sexual relationship.

Licensed sex therapists are particularly well suited to this task. Although they're qualified to understand the same broad emotional issues as individual or couples therapists, sex therapists have advanced training in addressing specific sexual problems, and they use a more targeted approach. Initially, underlying personal dilemmas and relationship conflicts are addressed only in the context of your sexual problems. As a result, sex therapy will probably return you to sexual functioning sooner than traditional counseling. However, once the sexual issue is resolved, many people continue working with the sex therapist or another mental health professional to tackle deeper personal and relationship issues.

Sex therapy in the age of erectile dysfunction drugs

When Viagra was first introduced, some sex therapists worried they would shortly be out of a job. But they soon learned otherwise.

Erectile dysfunction can set in motion a cycle of emotional and relationship problems that need addressing. Likewise, an instant "cure" in the form of a pill can uncover other sources of sexual dysfunction, such a low libido, difficulties with arousal, or vaginal pain from menopausal changes. If Viagra, Levitra, or Cialis allows you to resume sex after a hiatus, a sex therapist can help you transition back to sexual activity. These are some of the therapist's tasks:

Determining whether both members of the couple are comfortable with and committed to using the drug.
Discussing the conditions each person needs for pleasurable sex. For the woman, this may mean more romantic time that includes talking, affection, and sensual touching before moving to sexual activity. The therapist will also encourage the couple to learn how to adjust their lovemaking to incorporate the waiting period (if there is one) while the medication takes effect. (This interval may actually serve to encourage the type of sensual lovemaking that sex therapists recommend.)
Exploring expectations for resuming sex. The therapist can help you accept that sex will sometimes be just okay, that arousal problems may still occur, and that these medications won't work without desire and physical stimulation.
Addressing other sexual issues the man may have, such as ejaculatory problems.
Delving into emotional and relationship issues that are interfering with intimacy.
Devising strategies to deal with instances of unsuccessful intercourse.

What to expect during sex therapy

To understand what takes place during a sex therapy session, it's important to know what doesn't happen. Contrary to popular misconceptions, you will not undress in front of the sex therapist, make love while he or she is watching, or have sex with anyone other than your partner. If having to discuss your sex life with anyone other than your partner and perhaps your doctor is an obstacle to getting help, you can rest assured that the sex therapist will not push you too quickly. Also, part of the treatment process is learning how to talk about your sexual feelings more comfortably.

The role of sex therapy is to help people explore their sexual concerns, better communicate their sexual needs, and expand their repertoire of sexual and sensual activities. By increasing the overall pleasure and intimacy of sexual contact, a couple will be able to enjoy expressions of sensuality that are free from the goal-driven pressures of intercourse and orgasm.

Masters and Johnson pioneered sex therapy in the 1960s. The original model consisted of an intensive two-week treatment program revolving around daily therapy sessions. Couples traveled to the Masters and Johnson Institute and stayed in a hotel for the duration of the treatment. Although intensive weeklong or weekend programs are still available at a few centers around the country, most practitioners use a modified format in which the couple meets with the therapist in his or her office for weekly 50-minute sessions. There are certified sex therapists in most major cities, so you won't need to travel far from home to get help.

Much of the work of sex therapy is actually done at home between meetings with the therapist. After the initial getting-to-know-each-other period, the therapist will assign you and your partner materials to read or behavioral exercises to practice at home. You'll be asked to focus on your feelings and sensations during the assignment and to discuss them with the therapist in the next session.

The therapist may also serve as a sex educator. In many cases for example, with age-related changes or vaginal pain syndromes understanding the physiological basis of the problem often goes a long way toward relieving your anxiety, as well as your partner's. The therapist will discuss such issues with you during therapy sessions and may suggest useful books and videos. He or she will also challenge erroneous beliefs that stand in the way of enjoyable sex, such as "All sexual contact must lead to intercourse," "The man must be in charge of the sexual activity," or "Foreplay is only for teenagers."

Sex therapy can also help you learn to control other factors that inhibit your sexual performance. By understanding where stressors lie and how they influence sexual functioning, a couple can take steps to create a relaxed, distraction-free environment for sex. Older couples who need more time to reach arousal and orgasm may find they benefit from making an extra effort to set a romantic mood.

Overcoming anxiety about sex therapy

If you think sex therapy may be helpful but you're still uneasy about it, there are several ways to learn more about this treatment. Sexual self-help books and videos often describe exercises that a sex therapist might assign. Many even include a chapter explaining sex therapy. Your primary care doctor, gynecologist, or urologist may also be able to tell you something about the process.

Even if they understand what's involved in sex therapy, couples may be hesitant to take the first step. Anxieties revolve around the fear that something serious is wrong with them, that sex therapy will hurt their marriage by focusing too much on the problem, or that if the therapy doesn't work it means the situation is hopeless. During an initial phone call, a sex therapist will be able to address these issues and very likely ease your anxiety.

Sex therapy is most successful when both partners are willing participants. However, if one partner is resistant, the other may seek treatment alone. In this case, the sex therapist may encourage the hesitant partner to attend for at least one session in order to discuss his or her thoughts on the issue. If the partner is unwilling to engage in therapy even to this extent, it's still possible for the other partner to benefit from the process.

Sensate focus: The foundation of sex therapy

The cornerstone of sex therapy is a series of behavioral exercises called sensate focus exercises. These highly structured touching activities are designed to help you overcome performance anxiety and increase your comfort with physical intimacy. Sensate focus training also helps teach you about your partner's body as well as your own.

Initially, the couple agrees to refrain from intercourse or genital stimulation until the later stages of treatment. This helps dispel anxiety that's built up around sexual performance and allows you to establish new patterns of relating. Couples and therapists also negotiate how frequently the couple will perform the assigned exercises between therapy sessions.

Occasionally, couples are reluctant to complete the homework assignments. This too can be revealing. By delving into the roots of this resistance, the therapist can better understand the origins of the problem.

Helping yourself to a better sex life

Whether the problem is big or small, there are many things you can do to get your sex life back on track. Communicating with your partner, maintaining a healthy lifestyle, availing yourself of some of the many excellent self-help materials on the market, and just having fun can help you weather tough times.

Talking to your partner

Many couples find it difficult to talk about sex even under the best of circumstances. When sexual problems occur, feelings of hurt, shame, guilt, and resentment can halt conversation altogether. Because good communication is a cornerstone of a healthy relationship, establishing a dialogue is the first step not only to a better sex life, but also to a closer emotional bond. Here are some tips for tackling this sensitive subject.

Find the right time to talk. There are two types of sexual conversations: the ones you have in the bedroom and the ones you have elsewhere. It's perfectly appropriate to tell your partner what feels good in the middle of lovemaking, but it's best to wait until you're in a more neutral setting to discuss larger issues, such as mismatched sexual desire or orgasm troubles.

Avoid criticizing. Couch suggestions in positive terms, such as, "I really love it when you touch my hair lightly that way," rather than focusing on the negatives. Approach a sexual issue as a problem to be solved rather than an exercise in assigning blame.

Confide in your partner about changes in your body. If hot flashes are keeping you up at night or menopause has made your vagina dry, talk to your partner about these things. It's much better that he know what's really going on rather than interpret these physical changes as lack of interest. Likewise, if you're a man and you no longer get an erection just from the thought of sex, teach your partner how to touch you rather than let her think she isn't attractive enough to arouse you anymore.

Be honest. You may think you're protecting your partner's feelings by faking an orgasm, but in reality you're starting down a slippery slope. As challenging as it is to talk about any sexual problem, the difficulty level skyrockets once the issue is buried under years of lies, hurt, and resentment.

Don't equate love with sexual performance. Create an atmosphere of caring and tenderness. Don't blame yourself or your partner for your sexual difficulties. Focus instead on maintaining emotional and physical intimacy in your relationship.

Another potentially sensitive subject that's worth discussing is what will happen after one partner dies. In couples who enjoy a healthy sex life, the surviving partner will likely want to seek out a new partner. Expressing your openness to that possibility while you are both still alive will likely relieve guilt and make the process less difficult for the surviving partner.

Using self-help strategies

Treating sexual problems is easier now than ever before. Revolutionary medications and professional sex therapists are there if you need them. But you may be able to resolve minor sexual issues by making a few adjustments in your lovemaking style. Here are some things you can try at home.

Educate yourself. Plenty of good self-help materials are available for every type of sexual issue. Browse the Internet or your local bookstore, pick out a few resources that apply to you, and use them to help you and your partner become better informed about the problem. If talking directly is too difficult, you and your partner can underline passages that you particularly like and show them to each other.

Give yourself time. As you age, your sexual responses slow down. You and your partner can improve your chances of success by finding a quiet, comfortable, interruption-free setting for sex. Also, understand that the physical changes in your body mean that you'll need more time to get aroused and reach orgasm. When you think about it, spending more time having sex isn't a bad thing; working these physical necessities into your lovemaking routine can open up doors to a new kind of sexual experience.

Use lubrication. Often, the vaginal dryness that begins in perimenopause can be easily corrected with lubricating liquids and gels. Use these freely to avoid painful sex a problem that can snowball into flagging libido and growing relationship tensions. When lubricants no longer work, discuss other options with your doctor.

Maintain physical affection. Even if you're tired, tense, or upset about the problem, engaging in kissing and cuddling is essential for maintaining an emotional and physical bond.

Practice touching. The sensate focus techniques that sex therapists use can help you re-establish physical intimacy without feeling pressured. Many self-help books and educational videos offer variations on these exercises. You may also want to ask your partner to touch you in a manner that he or she would like to be touched. This will give you a better sense of how much pressure, from gentle to firm, you should use.

Try different positions. Developing a repertoire of different sexual positions not only adds interest to lovemaking, but can also help overcome problems. For example, the increased stimulation to the G-spot that occurs when a man enters his partner from behind can help the woman reach orgasm.

Write down your fantasies. This exercise can help you explore possible activities you think might be a turn-on for you or your partner.

Do Kegel exercises. Both men and women can improve their sexual fitness by exercising their pelvic floor muscles. To do these exercises, tighten the muscle you would use if you were trying to stop urine in midstream. Hold the contraction for two or three seconds, then release. Repeat 10 times. Try to do five sets a day. While these exercises can be done anywhere while driving, sitting at your desk, or standing in a checkout line in women they are most effective when you use vaginal weights to add muscle resistance. Talk to your doctor or a sex therapist about where to get these and how to use them.

Try to relax. Do something soothing together before having sex, such as playing a game or going out for a nice dinner. Or try relaxation techniques such as deep breathing exercises or yoga.

Use a vibrator. This device can help a woman learn about her own sexual response and allow her to show her partner what she likes.

Don't give up. If none of your efforts seem to work, don't give up hope. Your doctor can often determine the cause of your sexual problem and may be able to treat it with medication. He or she can also put you in touch with a sex therapist who can help you explore issues that may be standing in the way of a fulfilling sex life.

Maintaining good health

Your sexual well-being goes hand-in-hand with your overall mental, physical, and emotional health. Therefore, the same healthy habits you rely on to keep your body in shape can also shape up your sex life.

Exercise, exercise, exercise. Physical activity is first and foremost among the healthy behaviors that can improve your sexual functioning. Because physical arousal depends greatly on good blood flow, aerobic exercise (which strengthens your heart and blood vessels) is crucial. And exercise offers a wealth of other health benefits, from staving off heart disease, osteoporosis, and some forms of cancer to improving your mood and helping you get a better night's sleep. Also, don't forget to include strength training.

Don't smoke. Smoking contributes to peripheral vascular disease, which affects blood flow to the penis, clitoris, and vaginal tissues. In addition, women who smoke tend to go through menopause two years earlier than their nonsmoking counterparts. If you need help quitting, try nicotine gum or patches or ask your doctor about the drug bupropion (Zyban).

Use alcohol in moderation. Some men with erectile dysfunction find that having one drink can help them relax, but heavy use of alcohol can make matters worse. Alcohol can inhibit sexual reflexes by dulling the central nervous system. Drinking large amounts over a long period can damage the liver, leading to an increase in estrogen production in men. In women, alcohol can trigger hot flashes and disrupt sleep, compounding problems already present in menopause.

Eat right. Overindulgence in fatty foods leads to high blood cholesterol and obesity both major risk factors for cardiovascular disease. In addition, being overweight can promote lethargy and a poor body image.

Use it or lose it. When estrogen drops at menopause, the vaginal walls lose some of their elasticity. You can slow this process or even reverse it through sexual activity. If intercourse isn't an option, masturbation is just as effective, although for women, this is only effective if you use a vibrator or dildo. For men, long periods without an erection can deprive the penis of a portion of the oxygen-rich blood it needs to maintain good sexual functioning. As a result, something akin to scar tissue develops in muscle cells, which interferes with the ability of the penis to expand when blood flow is increased.

Putting the fun back into sex

Even in the best relationship, sex can become ho-hum after a number of years. With a little bit of imagination, you can rekindle the spark.

Be adventurous. Maybe you've never had sex on the kitchen floor or in a secluded spot in the woods; now might be the time to try it. Or try exploring erotic books and films. Even just the feeling of naughtiness you get from checking out an X-rated movie at the local video store might make you feel frisky.

Be sensual. Create an environment for lovemaking that appeals to all five of your senses. Concentrate on the feel of silk against your skin, the beat of a jazz tune, the perfumed scent of flowers around the room, the soft focus of candlelight, and the taste of ripe, juicy fruit. Use this heightened sensual awareness when making love to your partner.

Be playful. Leave love notes in your partner's pocket for him or her to find later. Take a bubble bath together the warm cozy feeling you have when you get out of the tub is a great lead-in to sex. Tickle. Laugh.

Be creative. Expand your sexual repertoire and vary your scripts. For example, if you're used to making love on Saturday night, choose Sunday morning instead. Experiment with new positions and activities. Try sex toys and sexy lingerie if you never have before.

Be romantic. Read poetry to each other under a tree on a hillside. Surprise each other with flowers when it isn't a special occasion. Plan a day when all you do is lie in bed, talk, and be intimate.

The most important tool you have at your disposal is your attitude about sexuality. Armed with good information and a positive outlook, you should be able to maintain a healthy sex life for many years to come.

Resources

Organizations

American Association of Sexuality Educators, Counselors, and Therapists www.aasect.org P.O. Box 1960 Ashland, VA 23005 804-752-0026

A nonprofit professional association of sex educators, sex counselors, and sex therapists. You can get a list of therapists in your area by searching the organization's Web site.

American Urological Association www.urologyhealth.org 1000 Corporate Blvd. Linthicum, MD 21090 866-746-4282 (toll free)

The Web site includes information on erectile dysfunction and a range of other adult urological conditions.

National Kidney and Urologic Diseases Information Clearinghouse http://kidney.niddk.nih.gov/ 3 Information Way Bethesda, MD 20892 800-891-5390 (toll free)

This government clearinghouse provides accurate, up-to-date information about kidney and urologic diseases to patients, health care professionals, and the public.

Books

Becoming Orgasmic: A Sexual and Personal Growth Program for Women Julia R. Heiman, Ph.D., and Joseph LoPiccolo, Ph.D. (Fireside, 1987, 219 pages)

This guide to female sexuality helps women of all ages understand their bodies and sources of sexual pleasure. The step-by-step program is designed to teach women how to identify their orgasm triggers.

Coping with Erectile Dysfunction: How to Regain Confidence and Enjoy Great Sex Michael E. Metz, Ph.D., and Barry W. McCarthy, Ph.D. (New Harbinger Publications, 2004, 168 pages)

Written by two sex therapists, this book addresses the biological, social, and psychological causes of erectile dysfunction. The comprehensive treatment plan encourages couples to work together to overcome the problem.

Coping with Premature Ejaculation: How to Overcome PE, Please Your Partner & Have Great Sex Michael E. Metz, Ph.D., and Barry W. McCarthy, Ph.D. (New Harbinger Publications, 2004, 170 pages)

This book addresses all types of premature ejaculation and provides the latest scientifically based treatments. It guides readers through the myths of male sexual performance and offers men a choice of recovery plans.

Making Love the Way We Used toor Better: Secrets to Satisfying Midlife Sexuality Alan M. Altman, M.D., and Laurie Ashner (Contemporary Books, 2001, 336 pages)

This guide for women and men facing the hormonal changes of midlife examines the most common sex-related problems couples encounter during these years and offers strategies for overcoming them.

The New Love and Sex After 60 Robert N. Butler, M.D., and Myrna I. Lewis, Ph.D. (Ballantine Books, 2002, 400 pages)

This book examines how aging affects sexual desire and lovemaking. It includes medical information on menopause and chronic diseases affecting sexuality, as well as tips for solving sexual problems and staying sexually fit.

The New Male Sexuality: The Truth about Men, Sex, and Pleasure Bernie Zilbergeld, Ph.D. (Bantam, 1999, 432 pages)

Written by a psychologist who specializes in human sexuality, this book offers a comprehensive guide to enhancing desire and arousal, with an emphasis on pleasure instead of performance.

The V Book: A Doctor's Guide to Complete Vulvovaginal Health Elizabeth G. Stewart, M.D., and Paula Spencer (Bantam, 2002, 480 pages)

This comprehensive book provides an in-depth description of women's vulvovaginal anatomy and functioning. It combines information on routine care with a thorough discussion of vaginal pain and other troublesome conditions.

Review Date: 2007-01-01

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