Programme

1. Ageing & Intimacy: Sexuality in later lifeDr Allyson Waite Registered Clinical PsychologistCo-Director Sex Therapy New Zealandwww.sextherapy.co.nz

2. Programme • Background • Myths and Reality of Ageing • Intimacy & Sexuality in later life • Biological factors and sexual function • Psychosocial factors and sexual function • Coping with change • Dementia and sexuality • Raising the issue

3. Preparation to be Sexual What sex education did you receive as you grew up? How well did this prepare you for becoming a sexual being? dealing with sexual concerns as a professional now?

5. Myths of Ageing & Sexuality • You have to be beautiful to be desirable. • You have to be young to have sex. • You have to have a partner to have sex. • If you’re widowed it’s the end of your sex life. • Older people should be looking after their grandchildren. • Older people can’t change. • Ageing and sexual dysfunction are inevitably linked. • Mixed messages – all in the mind/all decline • Derogatory terms – expressing sexuality

6. The Reality ofAgeing • Biological changes – impact on sexual function. • Chronic illness or disability; medications. • Losses: role, function, significant attachments & relationships (bereavement/divorce), identity, income (retirement) • Women outlive men (approx 7 years) • Unresolved past issues – trauma; attachment needs • Life stage issues - Erikson • Traditional beliefs and values tested • Anxiety – dependence, disease, death. • Diversity

7. Domains of Intimacy • Psychological • Emotional • Physical • Operational • Social • Spiritual

8. Health Benefits of Sexual ExpressionMitchell,S. & Owens, A.F.(Eds). (2007) Raising self esteem Recharging batteries Repair relationship distance/damage Rise in oxytocin Lower cancer risk Improved immunity Improved fertility Decreased vaginal atrophy and increased testosterone Lower mortality Analgesic effect

9. How important is sex in later life? The view of older people (Gott, M. & Hinchliff, S., 2003) • All with current sexual partner - some importance • Those rating greatest importance - context of emotional intimacy in their relationship as a whole • Those rating sex not particularly important - not in a sexual relationship/partnership • Minority - sex more pleasurable/greater importance with age • Experiencing barriers to being sexually active: (e.g. no partner or partner’s health problems) – some reprioritised importance of sex • Importance of non sexual touching to maintain physical intimacy

10. Sex for the Mature AdultWeeks, D.J. SRT 17/3, 2002 • Need to challenge myths re ageing and sexual dysfunction • Physiological changes exceeded by psychological, emotional issues and ageist beliefs • No fixed biological limit to a satisfactory sex life during old age. • Correlation with sexual activity and enjoyment before, during and after middle years. • More > less sexual activity related to increased sexual satisfaction within a relationship • Association between psychological health and sexual pleasure. • Sexual satisfaction - major contributor to quality of life, maintaining self esteem & good self concept. • Most prevalent problems partner/relationship related, lack of tenderness, partner problems

11. Sex & Nursing Home Care • Lack of partner • Lack of privacy • Lack of opportunity • Attitudes of staff • Chronic illness • Dementia and urinary incontinence. • Loss of interest • Loss of feelings of attractiveness

12. Biological Variables Impacting on Sexual Functioning in Older People. • Physiological changes – sexual function • Illness, disability, pain • Medical and surgical interventions • Medications • Tiredness, stress • Obesity

13. The Couple Sharing Long Term Illness (2004) d’Ardenne • Physical and psychological effects of illness – for both partners • When one becomes caregiver, the other dependent - nature of intimacy changes. • Caregiver may have to provide personal care • May lose free time and income; social isolation. • May have stress of watching suffering. • May be grieving ‘loss’ of companion. • May have huge frustration.

14. Psycho/social variables Impacting on Sexual Functioning in Older People. • Partner related problems • Relationship issues • Past traumatic sexual experiences • Unresolved emotional experiences • Self esteem, body image • Lack of education, knowledge • Social expectations/sexual culture

15. Coping with change and maintaining intimacy • Open communication • Acknowledging losses/changes - self/partner/relationship • Grief work • Changing expectations - rescripting – sex/intercourse • Broadening concept of sex and intimacy • Problem solving • Maintaining non sexual touch • Understanding changes • Dealing with potential sources of pressure • Dealing with anxiety and rebuilding confidence • Dealing with past issues – emotionally/sexually

17. Impact of Dementia onMarital Relationships Baikie (2002) • Majority of people with dementia live in community, often cared for by a spouse. • Relationships under these conditions require social support. • Carer stress • “Being neither a wife nor a widow”. • Loss of personality, not being recognised. • Demands on spouse: • Find a way to deal with their love of their partner • Deal with frustration, anger, grief etc. • Watch the devastating effects of the disease • Face the loss of their relationship • Assume major responsibility for care. • How spouse has experienced relationship before illness affects how they see role of caregiver now. • Partner has to change, person with dementia cannot. • Partner has to find a way to handle a sense of obligation to be sexual.

18. Aspects of Dementia which Challenge Intimacy • Verbal communication difficult. • Visual and hearing difficulties. • Complex tasks become more difficult. • Lack of initiative or withdrawal from usual activities. • Emotional and personality changes. • If fronto-temporal dementia: • Loss of the ability to empathise, • Behave inappropriately or in an uninhibited way, • Easily distracted.

19. Dementia’s Impact on Sexual Behaviours • Desire may decrease as a result of dementia • Desire may increase as a result of dementia. • They may be uninhibited - inappropriate • “Challenging behaviours” – carer stress • They may make unreasonable demands. • They may forget they recently had sex. • They may brood in response to refusals. • Co-ordination problems make caressing, penetration difficult. • They may forget to caress.

20. “Opening a can of worms…” • Barriers to managing sexual dysfunction in primary care: • Concerns about lack of knowledge, expertise, opening a floodgate, personal embarrassment, lack of time, sensitivity and complexity of issues, gender, culture, orientation • 22 GP’s – how do they perceive and manage sexual health concerns of older people • Sexuality generally not proactively pursued – sexual health seen as related to younger people – e.g. STI’s and contraception, discomfort with raising with this generation and not wishing to cause offence • Barrier’s from patients – 45 patients – aged 50-92 • Most saw GP as most appropriate person to approach. However, barriers included personal characteristics of the GP, shame embarrassment, fear of disapproval, judgement, attribution of problems to normal ageing,

21. PLISSIT • Permission • Limited Information • Specific Suggestions • Intensive Therapy

22. What you can do to help Open the door - “Its okay to talk to me about sex.” Encourage to talk Give information Listen – under rated! normalise reassure specific solutions – practical, PDE-5i’s, aids Clarify expectations/fears Differential diagnosis: disease/treatment side effect/psychogenic. Know where to refer on when needed

23. Raising the Topic of Sex • Find an opportunity: • When discussing lifestyle issues • When prescribing medication • In a general checkup, review etc • Create an opportunity: • Generalising • Normalising • Link to a diagnosed condition • Use statistics

24. Where to from here? • Referrals: • Sex Therapy New Zealand (STNZ) • www.sextherapy.co.nz • Further training: • The Good Fellow unit, University of Auckland • c.pilkington@auckland.ac.nz • Resources: • Sexuality – key facts for men over 50 • Sexuality – key facts for women over 50

26. References • Baikie, E. (2002) Impact of dementia on marital relationships., Sexual and Relationship Therapy17, 3, 290-299 • d’Ardenne, The Couple Sharing Long Term Illness. (2004) Sexual and Relationship Therapy,19/3, 2910-307 • Gott, M. & Hinchcliff, S. (2003) Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people. Family Practice, 20,6, 690-695 • Gott, M. & Hinchcliffe, S. (2003) How important is sex in later life? The views of older people. Social Science and Medicine, 56 (8) 1617-28 • Gott, M., Galena, E., Hinchcliff & Ellford, H. (2004) “Opening a can of worms:. GP and practice nurse barriers to talking about sexual health in primary care. Family Practice, 21, 5, 528-536 • Gott, M., Hinchcliff, S. & Galena, E. (2004) General practitioner attitudes to discussing sexual health issues with older people. Social Science & Medicine 58, 2093-2103 • Gott, M. (2005) Sexuality, Sexual Health & Ageing, Open University Press, New York • Hill, J., Bird, H & Thorpe, R. (2003) The effects of rheumatoid arthritis on sexual activity and relationships. Rheumatology, 24, 280-6. • Trudel, G., Turgeon, L. & Piche, L. (2000) Marital and Sexual aspects of old age. Sexual and Relationship Therapy. 15, 4, 381-381-406 • Watters. Y. & Boyd, T. (2009) Sexuality in later life: opportunity for reflection for health providers. Sexual and Relationship Therapy, 24, 3-4, 307-315 • Weeks, D.J.,(2002) Sex for the Mature Adult: self esteem and countering ageist stereotypes, Sexual and Relationship Therapy, 17/3 , 231-240

27. Assessment Sex Coaching for Physicians. MA Perelman (2003) International Journal of Impotence Research 15,5. The brief sex status exam: • Potential for cluster problems. • Personal distress. • Ask specific questions • Factors to look out for: • Lack of attraction or erotic energy. • Anxiety, anger, drug/alcohol effect. • Masturbation style, frequency & attitude. • Sexual expectations. • Get a comprehensive description of actual behaviour and cognitions: immediate, intermediate and remote causal layering. • GP’s can manage current obstacles to success (organic and psychogenic)- • Managing time crunch.

28. Treatment: general aspects (Perelman, 2003) • Modifying expectations. • Using drugs as a therapeutic probe. • Use follow-up to manage noncompliance and improve outcome: • schedule f/u appt day first prescribe • monitor side effect, assess success, alter dose if necessary, • ongoing education where necessary, • ensure compliance from patient and partner. • Bio psychosocial issues which can evoke non-compliance: • fear of complications • change associated with aging, chronic disease/injury • changes associated with medications • alcohol, smoking, life stressors • loss of partner, • partner’s attitude. • relapse prevention strategies.