Sexuality and quality of life in later life: overcoming old narratives, addressing new challenges

Abstract

Sexuality in later life has been traditionally defined through a narrative of decline, assuming that older adults have less sexual capacities and interests. However, such a view has been challenged by a new, more optimistic and inclusive paradigm of aging which recognizes the sexual needs and rights of older adults.

The World Health Organization (WHO) has declared the present decade (2021–2030) ‘the decade of healthy aging’, reflecting the commitment by all Member States to improve the lives of current and future generations of older people, an objective in line with the 2030 Agenda for Sustainable Development.

The concept of ‘healthy aging’, promoted by the WHO, was officially introduced in a 2015 report [1], where the conceptual model is defined, and its implications for health and long-term care systems are outlined. In this report, sexuality is included as a health characteristic of older adults, alongside other aspects such as mobility, sensory, cognitive, and immune functions. This is a welcome addition, as sexuality in older age has traditionally been neglected, based on the assumption that older adults are no longer interested in or capable of maintaining an active sexual life. Similarly, in many definitions of quality of life in older age, sexuality has been surprisingly absent, despite being a dimension clearly linked to other aspects of quality of life, such as life satisfaction, well-being, physical and cognitive health, autonomy, and independence [2].

It is evident that the physiological changes associated with aging can impact sexuality in both men and women. Furthermore, aging increases vulnerability to diseases that may directly affect sexual function (e.g., cardiovascular diseases) or involve pharmacological treatments with side effects impacting sexuality. Nevertheless, these changes do not imply that sexual expression no longer occurs in older age. Research shows that the most older adults, particularly those in developed countries, remain sexually active [3], and that sexual activity and intimacy are important predictors of life satisfaction and well-being [4].

The challenge to the traditional ‘narrative of decline’ regarding aging and sexuality was accompanied by a new, more optimistic paradigm of aging (‘successful aging’) which emphasizes remaining active, socially engaged, and healthy into advanced age. Several factors, including historical shifts in values, activism and social movements (e.g., feminism or LGBT rights), as well as technological and medical advancements (e.g., contraception or medication for erectile dysfunction), have contributed to and increased sexual freedom, dismantling ageist sexual taboos, and making sexual practices more accessible and acceptable for older adults. Consequently, newer generations of older adults are likely to adopt a more open attitude toward sexuality, with greater expectations of maintaining sexual activity and valuing the sexual dimension of later life more than previous generations. sexual health is increasingly recognized as a right that should be respected, protected, and fulfilled throughout the lifespan, including later life [5].

While this more open approach to sexuality in later life is highly welcomed, it also introduces new challenges and risks, which partially mirror those faced in the application of the successful aging paradigm in other gerontological contexts [6]. One such challenge is viewing sexuality in later life merely as an extension of sexuality in earlier stages. This perspective suggests that “good sex” in later life entails maintaining the possibility of experiencing ‘youthful sex.’ However, youthful models of sexuality often focus on a limited range of sexual behaviors, mainly limited to penetrative intercourse, and are overly outcome-oriented, emphasizing performance metrics (e.g., that is, the more orgasms, the harder, the more quickly-aroused, the better). These standards, reinforced by the biomedicalization of sexuality, equate ‘good sex’ with quantitative measures of sexual function. Consequently, setting youthful functionality as the benchmark for later-life sexual health not only overlooks biological and psychosocial age-related changes but may also push older adults to pursue increasingly unattainable goals.

To mitigate this risk, a more inclusive view of sexuality in later life is needed [7]. This perspective should acknowledge that aging brings changes, some perceived as losses but others as gains—such as accumulated sexual experience or have no contraception-related concerns, namely after menopause. A more inclusive view should include dimensions that are not directly influenced by increasing age: emotions, intimacy, and the enjoyment of one’s (and one’s partner’s) body [8]. It should value the journey of sex rather than focusing on performance. This paradigm shift also requires contributing to fostering more positive perceptions of aging, aging signs of aging, and older bodies,, thus freeing individuals from the societal pressure of maintaining a youthful appearance as a pre-condition to sexual attractiveness.

This process of transformation requires the contribution of research to identify the specificities of sexual expression, health and well-being in later life, understand the sexual needs of older people, and develop guidelines to guarantee their sexual rights. Although studies in this field have dramatically increased over the past few decades, not only from biomedical sciences but also from psychosocial and cultural disciplines, there remain significant gaps that require further investigation. Among these gaps, the following are noteworthy:

• Longitudinal studies to explore trajectories of sexual behavior throughout the aging process and determine the effect of health and biomedical factors as well as the impact of psychosocial events and transitions, and how older people adapt (or not) to such changes, are needed.

• Treatment outcomes studies developing and testing the feasibility and effectiveness of interventions directed at the improvement of sexuality-related outcomes in older age are lacking, particularly those conforming to the required standards for reporting trials.

• The aging process among people with diverse sexual orientations and gender identities is still poorly understood. While there are considerable studies on gay (men) aging [9], other groups, such as older lesbian women and transgender individuals, have attracted less research attention so far. This gap in researching sexual and gender diversity is particularly noticeable when linking older age to sexual health.

• Sexuality among people beyond community-dwelling older adults needs further exploration. The sexual needs and rights of people aging with disabilities, dementia, or those who are socially excluded deserve more research attention. Similarly, the management of sexuality in nursing homes and other care institutions continues to pose significant challenges [10].

• Most research on sexuality in later life has been conducted in Western, industrialized countries. Since sexuality is heavily influenced by cultural practices and religious values, more studies from other world regions, particularly the Global South, are needed to fully understand its diversity.

With this collection, focused on Sexual Health and Ageing, we invite submissions that explore the factors influencing sexual health in the second half of life, and particularly among older adults. Reports on interventions to promote sexual well-being in older age or mitigate adverse effects of age on sexual function, analysis of the role of healthcare providers in addressing the sexual needs of aging populations, or explorations on societal stigmas and other barriers associated with the sexual needs and rights in later life are also welcomed. BMC Geriatrics aims to contribute to advancing and disseminating cutting-edge research on sexuality in later life, offering insights into the clinical, social, and cultural implications of sexuality in the aging process. As having a satisfactory sexual life should be considered an essential component of aging well, a better understanding of these implications will enhance the quality of life for both current older adults and future generations who will enter this stage of life in the coming years.