11.5: Sexuality in Middle Adulthood
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People in mid-adulthood continue to be sexually active. In fact, some find themselves leading some of the most sexually fulfilling years of their lives. Women in their 40s are more likely to reach orgasm than younger and older women because they have had more opportunities to learn about their sexuality and be more secure in their relationships. Relationship security promotes orgasmic consistency among women. The 1992 National Health and Social Life Survey, (NHSLS) data shows that married women are most likely to reach orgasm consistently, followed by cohabiting women, then single women regardless of racial or ethnic differences. The analysis of NHSLS data by Laura Carpenter (2009) found that among 1,053 heterosexual participants of study aged 40 to 59, women were less likely to be sexually satisfied than men were and there is a reversal of gender-role stereotype among people in midlife: women's emotional satisfaction was closely associated with bodily sexual practices, whereas men's physical pleasure was linked to relational factors. Midlife is the time when physical changes and changes in sexual response occur as the years pass; however, sexual activity among people in all age groups is influenced not only by physical changes but also by psychological well-being, feeling of intimacy, and cultural expectation.
It sounds so daunting and downright sad. The truth is , even with its side effects, it is freedom. Even with the night sweats , and mood swings, I am all in. This is the first time I’ve had autonomy over my body. I do not get my period. I do not need to buy tampons or pads. I cannot get pregnant. People stop asking you dumb questions like “are you going to have more kids?” My body, myself is all mine now.
Your body is constantly changing. Moving with the change instead of fighting the change has allowed me to let go of crazy, unhealthy ideas of how a woman my age should be. I feel the most attractive and sexy when I’m doing what I love, which is yoga , working with my dogs, and gardening while a bit stoned. So my wardrobe is mainly yoga pants or jeans, tank top and a truckers cap. I have dirt under my nails, my hair is in a ponytail, and my make up consists of tinted sunscreen. I am attractive to myself. I feel sexy to me. This is an epic mind shift. If I feel good, then that is magic. I don’t feel the urge to lure someone in with a false sense of being. I don’t want to have bad sex with someone just to feel desired. I’d rather have good sex with myself. It’s not that I wouldn’t like having a partner, I would. But I am certainly not going to sacrifice anything to get there.
Midlife Transitions
Female Sexual and Reproductive Health: Perimenopause refers to a period of transition in which a woman's ovaries stop releasing eggs and the level of estrogen and progesterone production decreases. Menopause is defined as 12 months without menstruation. The average age of menopause is approximately 51, however, many women begin experiencing symptoms in their 40s. These symptoms occur during perimenopause, which can occur 2 to 8 years before menopause (Huang, 2007). A woman may first begin to notice that her periods are more or less frequent than before. After a year without menstruation, a woman is considered menopausal and no longer capable of reproduction.
Symptoms: The symptoms that occur during perimenopause and menopause are typically caused by the decreased production of estrogen and progesterone (North American Menopause Society, 2016). The shifting hormones can contribute to the inability to fall asleep. Additionally, the declining levels of estrogen may make a woman more susceptible to environmental factors and stressors which disrupt sleep. A hot flash is a surge of adrenaline that can awaken the brain from sleep. It often produces sweat and a change of temperature that can be disruptive to sleep and comfort levels. Unfortunately, it may take time for adrenaline to recede and allow sleep to occur again (National Sleep Foundation, 2016).
The loss of estrogen also affects vaginal lubrication which diminishes and becomes waterier and can contribute to pain during intercourse. The vaginal wall also becomes thinner, and less elastic. Estrogen is also important for bone formation and growth, and decreased estrogen can cause osteoporosis resulting in decreased bone mass. Depression, irritability, and weight gain are often associated with menopause, but they are not menopausal (Avis, Stellato & Crawford, 2001; Rossi, 2004). Women vary greatly in the extent to which these symptoms are experienced. Most American women go through menopause with few problems (Carroll, 2016). Overall, menopause is not seen as universally distressing (Lachman, 2004).
Hormone Replacement Therapy: Concerns about the effects of hormone replacement have changed the frequency with which estrogen replacement and hormone replacement therapies have been prescribed for menopausal women. Estrogen replacement therapy was once commonly used to treat menopausal symptoms. However, more recently, hormone replacement therapy has been associated with breast cancer, stroke, and the development of blood clots (NIH, 2007). Most women do not have symptoms severe enough to warrant estrogen or hormone replacement therapy but for some it is very uncomfortable and unsettling. For those experiencing symptoms that are unmanageable they can be treated with lower doses of estrogen and monitored with more frequent breast and pelvic exams. Some natural ways to reduce symptoms are avoiding caffeine and alcohol, eating soy, remaining sexually active, practicing relaxation techniques, and using lubricants during intercourse.
Menopause and Ethnicity: In a review of studies that mentioned menopause, symptoms varied greatly across countries, geographic regions, and even across ethnic groups within the same region (Palacios, Henderson, & Siseles, 2010). For example, the Study of Women's Health across the Nation (SWAN) examined 14,906 white, African American, Hispanic, Japanese American, and Chinese American women's menopausal experiences (Avis et al., 2001). After controlling for age, educational level, general health status, and economic stressors, white women were more likely to disclose symptoms of depression, irritability, forgetfulness, and headaches compared to women in the other racial/ethnic groups. African American women experienced more night sweats, but this varied across research sites. Finally, Chinese American and Japanese American women reported fewer menopausal symptoms when compared to the women in the other groups. Overall, the Chinese and Japanese group reported the fewest symptoms, while white women reported more mental health symptoms and African American women reported more physical symptoms.
Cultural Differences: Cultural influences seem to also play a role in the way menopause is experienced. While some women focus on menopause as a loss of youth, womanhood, and physical attractiveness, career-oriented women tend to think of menopause as a liberating experience. In India, 94% of women said they welcome menopause. Aging women gain status and prestige and no longer have to go through self-imposed menstrual restrictions, which may contribute to Indian women’s experiences (Kaur, Walia, & Singh, 2004). Overall, menopause signifies many different things to women around the world and there is no typical experience. Further, by normalizing rather than pathologizing menopause this life transition can shift the perspective of many who see it as a negative life change.
Many times in my life, the monthly “visit from Aunt Flo” was unwelcomed, whereas certain times it was a giant relief. Overall it was a big part of my identity and when it went away, I had to reimagine. For some menopause means loosing something, for others it means gaining. However you look at it, it is a time of change that can be marked with celebration or reflection. There are various celebrations worldwide to mark the occasion, often likening it as stepping into wisdom and many have written about the journey. Here’s a link to one I like: My Menopausal Ritual
Male Sexual and Reproductive Health
Males continue to produce sperm and can father children throughout middle adulthood. Changes that occur in middle adulthood include erectile dysfunction (ED). Erectile dysfunction refers to the inability to achieve an erection or an inconsistent ability to achieve an erection (Swierzewski, 2015). Intermittent ED affects as many as 50% of men between the ages of 40 and 70. About 30 million men in the United States experience chronic ED, and the percentages increase with age. Approximately 4% of men in their 40s, 17% of men in their 60s, and 47% of men older than 75 experience chronic ED.
Causes for ED are primarily due to medical conditions, including diabetes, kidney disease, alcoholism, and atherosclerosis (build-up of plaque in the arteries). Plaque is made up of fat, cholesterol, calcium and other substances found in the blood. Over time plaque builds up, hardens, and restricts the blood flow in the arteries (NIH, 2014d). This build-up limits the flow of oxygenated blood to organs and the penis. Overall, diseases account for 70% of chronic ED, while psychological factors, such as stress, depression and anxiety account for 10%-20% of all cases. Many of these causes are treatable, and ED is not an inevitable result of aging. For more on ED, see Chapter 13 on Sexual Health.
Men during middle adulthood may also experience prostate enlargement, which can interfere with urination, and deficient testosterone levels which decline throughout adulthood, but especially after age 50. If testosterone levels decline significantly, it is referred to as andropause or late-onset hypogonadism. Identifying whether testosterone levels are low is difficult because individual blood levels vary greatly. Low testosterone is not a concern unless it accompanied by negative symptoms such as low sex drive, ED, fatigue, loss of muscle, loss of body hair, or breast enlargement. Low testosterone is also associated with medical conditions, such as diabetes, obesity, high blood pressure, and testicular cancer. The effectiveness of supplemental testosterone is mixed, and long term testosterone replacement therapy for men can increase the risk of prostate cancer, blood clots, heart attack and stroke (WebMD, 2016). Most men with low testosterone do not have related problems (Berkeley Wellness, 2011).
The Midlife Transition and Sexuality
Sexuality is an important part of people's lives at any age, and many older adults are very interested in staying sexually active (Dimah & Dimah, 2004). According to the National Survey of Sexual Health and Behavior (NSSHB) , 74% of males and 70% of females aged 40-49 engaged in vaginal intercourse during the previous year, while 58% of males and 51% of females aged 50-59 did so (Center for Sexual Health Promotion, 2010).
Despite these percentages indicating that middle adults are sexually active, age-related physical changes can affect sexual functioning. For women, decreased sexual desire and pain during vaginal intercourse because of the hormonal changes have been identified (Schick et al., 2010). A woman may also notice less vaginal lubrication during arousal which can affect overall pleasure (Carroll, 2016). Men may require more direct stimulation for an erection and the erection may be delayed or less firm (Carroll, 2016). As previously discussed men may experience erectile dysfunction or experience medical conditions (such as diabetes or heart disease) that impact sexual functioning. Couples can continue to enjoy physical intimacy and may engage in more foreplay, oral sex, and other forms of sexual expression rather than focusing as much on sexual intercourse.
It is important to note that risk of pregnancy continues until a woman has been without menstruation for at least 12 months and couples where pregnancy is possible should continue to use contraception. People continue to be at risk of contracting sexually transmitted infections, such as genital herpes, chlamydia, and genital warts. In 2014, 16.7% of the country’s new HIV diagnoses (7,391 of 44,071) were among people 50 and older, according to the Centers for Disease Control and Prevention (2014e). This was an increase from 15.4% in 2005. Hopefully, when partners understand how aging affects sexual expression, they will be less likely to misinterpret these changes as a lack of sexual interest or displeasure in the partner and more able to continue to have satisfying and safe sexual relationships. Practicing safe sex is important at any age, yet adults over the age of 40 have the lowest rates of condom use (Center for Sexual Health Promotion, 2010).