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Seniors and Sexuality

A Live Chat with Author Walter Bortz, M.D.
By: Network of Care

The following live chat occurred Jan. 10, 2002, on Network of Care.

NOC Moderator: Good evening, and welcome to Network of Care’s live chat on seniors and sexuality. We are honored to present our special guest, Walter Bortz, M.D., noted author, geriatrician and expert on aging issues. Dr. Bortz, 70, has practiced medicine for almost 40 years. He has published more than 100 scholarly papers in academic and medical journals, as well as articles in the New York Times, Washington Post, San Francisco Chronicle, Town & Country and Runner's World. His best-selling books, “Living Longer for Dummies,” "We Live Too Short and Die Too Long" and "Dare to Be 100," have been published in the U.S., Japan, Italy and the Netherlands. Dr. Bortz is past president of the American Geriatrics Society and co-chairman of the American Medical Association’s Task Force on Aging. He has been married for 48 years, and he and his wife, Ruth, have four children and nine grandchildren. He stresses physical and mental activity as the key to longevity. Welcome, Dr. Bortz! Thank you so much for joining us tonight.

Guest Expert Walter Bortz: Good evening, everyone, and welcome to a fun and hopefully important experience for all of us. You have heard all of my important credentials. But among all this puffery, several years ago I recognized that I was missing a competence in an important area of growing older, and that was sexuality. The way I have found to become an expert is to do a research project. As a result of this, I have now conducted three separate research projects dealing with aging and sexuality, all of which have been published in major medical journals. However, this is not just my scientific interest. It also nourishes my personal life at age 71, happily married for almost 49 years, trying to figure out what it is all about. Therefore, I am hoping this evening will help me help you – and maybe, you help me.

NOC Moderator: Chat participants, we welcome your questions about the physical, emotional and mental aspects of late-life sexuality. Dr. Bortz will answer as many of your questions as time allows. To get us started, please give us an overall view of sexuality in aging. How important is sexuality in aging? How much is it misunderstood? What are the benefits of sexuality for the aging?

Guest Expert Walter Bortz: We talk about how long we live, but more important is how well we live. There is no question in my mind that sexuality is a major quality-of-life issue. The major problem is that this issue has languished with ignorance forever. Robert Butler, the first director of the National Institute on Aging, saw late-life sexuality as a mythology fed by misinformation. Masters and Johnson wrote, "Can that one facet of our lives, affecting more people in more ways than any other physiological response other than those necessary to our existence, be allowed to continue without benefit of objective, scientific analysis?" All of this said that until now, sexuality and aging has been a closet issue. It has been a shame and an embarrassment. Now it is coming out into the open, and we'll all be the better because of it.

Susan D.: Is there a way of acknowledging and reassuring seniors that it is OK to still feel and be sexually active without insulting their dignity?

Guest Expert Walter Bortz: Dignity is an individual issue. Sexuality is either dignified or not, depending on the personal attitudes. I personally am convinced that sexuality until one's last days is an integral part of living a full life. When we die, we want to be able to say, “I've lived, fully.” And living fully means exploring our sexual interests and competence as late in life as possible.

Kitty: As a 59-year-old woman, I no longer feel comfortable with "penetration sex" – i.e. my vagina is rather dry and stiff. I don't take estrogen anymore. I tried an Estring, but it didn't fit. I haven't really tried the cream consistently – would that help? What else might help?

Guest Expert Walter Bortz: There is no question whatever that as women age, their loss of estrogen results in major changes to vaginal sensitivity. Uncomfortable sex is an all too common result of this atrophy of the vaginal tissues. The simple and direct approach to this is the use of local estrogen cream, which restores the natural lubricating surface of the vagina and thereby enables satisfactory intercourse.

Donald: What about sex in a nursing home? Issues of morals (especially if one’s facility is “faith-based”), privacy, how staff can “assist” in making the experience both pleasurable and positive, are live issues with long-term care staff.

Guest Expert Walter Bortz: This question is wonderful. It explores the depth of our prejudice and ignorance. Because a person is in an institution does not depersonalize that individual. The staff of the institution should be charged with expanding the personal experience of every resident. If this happens to coincide with the desires of two residents for sexual intimacy, it is my firm position that that desire should be facilitated by clever, creative initiative.

Donald: What about sex between a cognitively intact person and one who has cognitive impairments? There is the issue of autonomy but also the issue of “protection” of the vulnerable.

Guest Expert Walter Bortz: We are exploring areas that are unknown territory. In my judgment, sex is a consensual act. And if one person is not fully participatory, I would have major reservations about the sanction of that act.

Service Provider: Where does the responsibility lie at an assisted living facility? Does the family who may be paying the fees expect the facility to keep Mom from having sex with whoever she may choose? It seems like a fine line, especially when there is also dementia involved.

Guest Expert Walter Bortz: Certainly, the appropriate answer must be set out in advance. Although permissiveness is a generous posture to assume, this permissiveness implies a high degree of responsibility of all those who are involved. Although a sexual experience could not be mooted in such an environment, its encouragement could require a high degree of overview and early planning. The time to encounter such issues is before they happen, rather than after.

Celestia-Moon: My dad told me that since his prostate cancer treatment, he hasn’t been able to have intercourse with my mom. They had a very active sex life until this happened. She’s upset because she thinks he’s lost interest in her. Viagra didn’t work for him. What do you suggest for couples in this situation?

Guest Expert Walter Bortz: Male sexuality involves four separate issues. The first is interest, the other name for which is libido, and fundamentally depends on the level of testosterone derived from the male testicle. The second issue concerns hydraulics, which is simply the capacity of men to achieve a satisfactory erection. This process has been obscured until recently. Now we can identify and characterize the important issues very specifically. The third issue with satisfactory sexuality for males concerns sensory perception. And the fourth and critical issue concerns the receptivity of one's partner. Each of these four components are crucial to a successful sex pattern for older men.

Service Provider: Are senior citizens at risk for STDs?

Guest Expert Walter Bortz: Sexually transmitted diseases are not age-sensitive, although they concentrate in the younger age groups. The key word is responsibility. Because a person becomes older does not insulate a person from responsible sexual behavior. Therefore, one needs to maintain over an entire life experience an awareness that sexual exploration carries with it a health risk.

Brubron: Sometimes you hear that sex is good for the prostate; then, you hear that it is a strain on the prostate – what is the truth here?

Guest Expert Walter Bortz: The difficulty with the prostate and late-life problems concerns a nerve that runs nearby. If surgical intervention is used for prostate problems of whatever sort, there should be major efforts on the part of the surgeon made to protect this crucial nerve. Many prostate operations result in impotencies; however, skilled surgeons should have this awareness fully in mind when prostate operations are undertaken.

Brubron: What about sex? Is it good for the prostate, or bad?

Guest Expert Walter Bortz: The term that I resort to over and over is, “Use it or lose it.” The prostate is a walnut-size gland that lies deep within the male pelvis whose purpose it is to provide the fluid in which the sperm are suspended. Therefore, the more this gland is stimulated by sexual use, the more effective will be its function.

Brubron: Is there a problem with too much sex – such as coronary problems?

Guest Expert Walter Bortz: That is a terrific question. Sex is exercise and as such can be overdone. But the definition of overdone is extreme. There is a wonderful quotation within an editorial that was published in the British Medical Journal. It stated, "What we thought was bad for you may actually be good for you, but it may not be good to tell you, in case you do it too much, and it is certainly not good to tell you it is good for you if you do too much of it already.” This quote was published in reference to an article titled "Sex and Death: Are They Related?" This title referred to a research study conducted in Belfast, Ireland. One thousand men were asked about their frequency of sexual intercourse. Ten years later, they were re-surveyed. And those men who were the least sexually active were found to have much higher death rates than those who were robust in their sex. When all the issues were adjusted, the men who were in the sexually active group had only one-half the mortality of the inactive group, suggesting that sex is good for you. But you and I knew that already.

Al Bundy: Viagra’s been out for a while. What’s the latest on its effectiveness? How widespread is its use? Is it effective for very old people?

Guest Expert Walter Bortz: Someone has said that Viagra works even on corpses. It is one of the most successful drugs in the history of the American pharmaceutical industry. Its sales are phenomenal. Viagra is a very important drug which changed the entire face of older male sexuality and thereby older female sexuality as well. Our studies of older persons' sexuality indicate that impotency is the overwhelming No. 1 concern of older men; for women, the issue is availability of capable men. So, the two issues intersect. Viagra has been found to be incredibly helpful for a huge number of older men suffering from impotency. Viagra works by increasing the blood flow to the male penis and helping in the securing of a firm erection. It is true that Viagra has had some side effects. But almost all of these have been confined to men who have had prior problems of heart trouble and were taking drugs of the nitrate category. Viagra was originally developed as a blood-pressure-lowering medicine, for which it was shown not to be very effective. However, when it is used in combination with other medications, such as the nitrates, Viagra can precipitate a severe fall in pressure, which can prove disastrous. For this reason, Viagra should never be prescribed for a man who is taking nitroglycerine.

Molly74: We all know we’re not supposed to take other people’s prescriptions, but in the real world, it happens. Is it dangerous for a woman to take a man’s Viagra pill? Is there a Viagra for women?

Guest Expert Walter Bortz: Once again, a terrific question. Pfizer, which makes Viagra, has been searching for a female usage of the drug. To date, this has not been fulfilled. On a theoretical basis, Viagra should improve female sexuality as well as male sexuality, since its action is to increase blood supply to the genital area. The number of scientific studies that have been conducted with women so far have been inconclusive, and therefore at this date, Viagra cannot be considered to be documented as a major sexual aid for females as it is for males.

Brubron: I have heard many stories of men using Viagra who are not sexually impaired – but find that it enhances sex. What do you think about this kind of use of Viagra?

Guest Expert Walter Bortz: This question concerns a nontraditional use of a pharmaceutical product and therefore, there are no reliable data on which to base a response. Drugs are always designed to repair a deficit and not to exaggerate a competency which already exists. Therefore, the issue of Viagra's use in an otherwise normal individual to exaggerate average function is simply not an issue for which adequate information is available.

Celestia-Moon: Much has been made of sexual dysfunction in men caused by medications. Are there medications that cause decreased sex drive in women?

Guest Expert Walter Bortz: The same issues apply for women as men, but less so. There is a long list of commonly used drugs which affect male sexual performance. Most commonly, these involve the blood-pressure-lowering medicines and the antidepressants. These affect the blood vessel aspect of adequate sexual performance. For women, the issue is much more psychological than physiological. Therefore, medications such as sedatives, tranquilizers and the like, which affect a person's alertness and enthusiasm, can logically affect negatively their sexual interest and responsiveness.

Al Bundy: What effect does menopause have on a woman’s sex life?

Guest Expert Walter Bortz: At menopause, women suffer an abrupt loss of estrogen. This has many physical results on her anatomy and function. But probably more important than the physical changes of menopause are the psychological. These can be either liberating or confining. If the menopausal female sees her lifetime as loss of reproductive capability, this can constitute a negative psychological message. On the other hand, if the same woman assumes that menopause represents a release from fear of pregnancy and liberation, then her sexuality can expand into domains that she has never experienced before.

YoungAtHeart: I've been married to my second husband for 18 years. We're both 64 years young. We have sexual relations maybe twice a month, or maybe three or four times a month, it can vary for us. My question is, how does this rate of intercourse compare to other couples our age? And what can we expect in terms of frequency as we get older? I know we're not in competition with the rest of America, I'm just curious. Thank you.

Guest Expert Walter Bortz: Thank you for the openness of your question. We certainly do not have an adequate information base to which your question can be placed with credibility. My approach, therefore, to your question is that whatever you are doing is probably not as much as you could be doing. Therefore, expansion is the predominant message. This advisory is generic, because none of us, as we age, are doing as much as we could or should in any of our exploratory domains. The closer we can adhere to our earlier life ideals, the better we'll be the remainder of our days.

Jane: Societal views on sexuality changed drastically with the introduction of contraception. Do you think societal views on aging and sexuality likewise will change with the increase in senior population?

Guest Expert Walter Bortz: One of the great optimistic signs of our times is the enlightenment about late-life sexuality. It is my firm belief that as late-life sexuality is celebrated as a major life-quality issue and taken out of the closet where it has languished for so long, all of our lives will be brighter, more energized and more optimistic as a result.

NOC Moderator: And here’s our last question for you, Dr. Bortz: What three recommendations do you have for seniors, relative to late-life sexuality?

Guest Expert Walter Bortz: The first recommendation is to stay healthy. People who maintain their vigor, vitality and other domains of their lives are found to be exemplars of late-life sexuality. The second advice is to be wary of the medications you are taking, because many of these have negative effects on sex. And the third is to be sure to have a compatible, loving mate the last decades of your lives, as long as they may extend.

NOC Moderator: Dr. Bortz, do you have any last thoughts you’d like to offer our chat participants tonight? Guest Expert Walter Bortz: This has been such fun, and I hope it was for you. It is a topic of incredible importance. It is refreshing to be able to discuss it in an open forum such as this. I hope all of our lives go better because of it. Good evening, and Happy New Year.

Brubron: Dr. Bortz, thank you so much for being on the Network of Care chat – this is such an important topic, and you were terrific. I wish you would come back!!!!

Kitty: Thank you from me as well.

NOC Moderator: Walter Bortz, we thank you so much for sharing your time and knowledge with us. And thanks to everyone who joined us tonight and participated. Good night!