Chapter 41: Sexuality, Sexual Function, and the Aging Woman

Sociological evidence about sexuality of women in middle and later life has increased substantially over the last decade, but sexual function and outcomes among middle age and older women are still largely overlooked in the context of medical care. Negative societal attitudes about aging, sexuality among older people, and women’s sexuality in particular, present a significant barrier to scientific inquiry and medical attention to older women’s health concerns. Proven interventions for promoting female sexual well-being or treating women’s sexual problems are limited. Although older women experience high rates of sexual problems and the majority of partnered older women are sexually active, physicians infrequently discuss sexual health with older women. Public health attention to older women’s sexuality remains sparse.

The 2005–2006 National Social Life, Health and Aging Project (NSHAP), funded by the National Institutes of Health, provided the first comprehensive, population-representative biosocial data on sexuality among middle age and older women and men in the United States, and it informs many of the insights presented in this chapter. The study enrolled a national probability sample of 3005 community-residing men and women aged 57 to 85 (75.5% weighted response rate), with oversampling of African-American and Hispanic people, and men in the 75- to 85-year-old age group. About half the respondents were male, half were female, and they were divided approximately equally across three age strata: 57 to 64, 65 to 74, and 75 to 85 years. Respondents participated in a face-to-face questionnaire covering social, psychological, and health domains, including detailed information on sexual relationships and functioning. In 2010 and 2011, 75% of participants in the baseline NSHAP study (Wave I) participated in follow-up interviews as part of NSHAP Wave II, providing data to understand within-individual change over time.

This chapter first locates older women’s sexuality in a sociodemographic context, then describes sexual activity, behaviors, and problems experienced by women in later life; reviews physiologic changes that affect sexual functioning as women age; and recommends a clinical approach to evaluation, prevention, and treatment of sexual problems common among older women. Older women, and their sexual relationships, are very heterogeneous. Generalizations made in this chapter, based on population data from the NSHAP study and findings from other sources, are rooted in statistical norms but should not be interpreted as a normative prescription for older women’s sexuality.

Interactive Biopsychosocial Model

The interactive biopsychosocial model (IBM) provides a conceptual framework for understanding the relationship between sexuality and health throughout the life course (Figure 41-1). To the degree that medicine attends to matters of sexuality, the orientation is largely negative. The medical model approach to understanding sexuality focuses on sexual dysfunction as a problematic consequence of aging, disease, or treatment. Occasionally, medical texts suggest that older patients’ complaints about sexual problems, particularly male erectile difficulties, may herald serious underlying disease and ought not be ignored. Growing attention to older adult sexuality has been prompted by the greater longevity of individuals living with HIV and concerns of an increase in sexually transmitted infections (STIs) among older adults. While clinically valid, this narrow conceptualization of sexuality defies its multidimensional nature and limits understanding of the meaning of sexuality for health and the iatrogenic causes of sexual problems or dysfunction.

A broader framework, as defined by the IBM, conceptualizes a bidirectional relationship between sexuality and health. Sexual behavior can result in health problems, such as sexually transmitted infection, victimization, and, in younger women, unwanted pregnancy. Aging, physical and mental health problems, surgeries, medications, and other medical treatments can cause sexual dysfunction. The IBM acknowledges this reciprocal relationship between sexuality and health but incorporates the possibilities that sexuality may also be health-promoting and that aging, or even illness, may confer advantages for sexual life.

In this model, health comprises biological, psychological, and social components and is conceptualized as jointly produced by a woman in conjunction with her spouse or other intimate partner(s). Joint production of health means that partners contribute assets (or liabilities) to the “health endowment,” and these assets and liabilities impact the health of the other(s). The hourglass shape symbolizes the dynamic nature of both health and intimate relationships over time. Clinically, this model can be used as a mnemonic for the broad domains of inquiry pertinent to assessing a patient’s sexual history and reminds the clinician of the importance of ascertaining the presence, and health, of the patient’s intimate partner(s).

Sexuality in later life for most, but not all, people occurs in the context of a long-term marital relationship. For men, aging is largely a partnered experience. Men are significantly more likely than women to have a spouse or other romantic partner in later life and to be engaging in a satisfying sexual relationship, despite a high prevalence of erectile difficulties. As a result of greater longevity, women, in contrast, are much more likely to experience aging, illness, and death without their life partner (Figure 41-2).

Still, many older women regard sexuality as important for health and relationships and, among those with a spousal or other intimate relationship, many engage in regular sexual activity. Women tend to be less satisfied with sex in later life than men, and they also report a high frequency of sexual problems including low desire, vaginal dryness, and difficulty experiencing orgasm. An older married woman is often healthier and more vital than her spouse and commonly assumes a caregiver role, which can interfere with the romantic dynamic of the relationship. Physical health problems, medications, and medical treatments affect the sexual lives of older couples; older heterosexual adults with a spouse or other intimate partner who are not sexually active most commonly attribute this to the male partner’s health problems.

Sexuality is widely valued by older adults, even those without a partner, as an important aspect of health and life. In his 2001 report, the US Surgeon General David Satcher acknowledged that “sexuality is an integral part of human life. … Sexual health is inextricably bound to physical and mental health. … [It] is not limited to the absence of disease or dysfunction, nor is its importance confined to just the reproductive years.”

Although some aspects of aging are regarded as detrimental to sexual life, older women also identify ways in which aging is beneficial for sexuality (Table 41-1).

Lack of formal sexuality education combined with widely restrictive social, religious, and cultural practices around female sexuality during much of the twentieth century have influenced the current generation of older women’s sexual expectations throughout their lives. As a result, many report that they have never discussed nor would they initiate discussion of sexual matters with anyone, including their spouses. Most older women report that they have never spoken of sexual matters with a physician, yet feel that sexuality is an appropriate issue for physicians to address and that the physician, rather than the patient, should initiate the discussion (Table 41-2). Gender and age differences between women and their physicians can also present barriers to communication about sexual matters. In addition, older women perceive physicians to be poorly trained to deal with patients’ sexual concerns and that physicians presume older women to be asexual or disinterested (see Table 41-2).

Aging of the baby boomers, the generation of the sexual revolution, is expected to increase demand for medical attention to sexual matters over the next several decades. Although male longevity is expected to increase, older women will continue to outnumber older men through 2050; this presents a significant gender disparity in the opportunity for formation of new sexual relationships in later life and, in some cases, results in multiple women sharing a single male partner. Little is known about the health implications of emerging trends among older adults including nonmonogamy, rising rates of divorce, unmarried cohabitation, same-sex marriages and later life dating.

Sexuality in Long-Term Care Institutions and Palliative Care

The early literature on sexuality and aging was prompted by the “problem” of sexual activity and behavior in the nursing home or long-term care setting and contemplated strategies for staff to manage—mainly to eliminate—this behavior. Over time, sexual behavior in the context of dementia, specifically, has become understood as a normal behavior that in some cases is intended to be sexual and in other cases is a manner of communicating other needs. Residents of long-term care institutions are less likely to be sexually active than community-residing older adults, and they cite lack of partners, lack of privacy, lack of interest, sexual dysfunction, and negative attitudes of staff as limiting sexual expression. Older lesbian, bisexual, and transgender individuals are at increased risk of stigma and discrimination, especially in settings where the right to privacy is not permitted.

Increasingly, as a human rights matter, long-term care institutions provide private rooms for residents and have trained their providers to understand and accept elder sexuality in a respectful manner. Sometimes, sexual relationships form among people with dementia who have, but may not remember, a community-residing spouse. Likewise, community-residing spouses may initiate new intimate relationships while maintaining involvement with and commitment to their institutionalized spouse. The implications of these relationships for health and integrity in later life are a growing reality, but poorly understood and often a cause of distress for families. Sexual exploitation and abuse of older women living in residential facilities (and in the community) are poorly documented, but vulnerability is heightened by cognitive impairment, which can interfere with a woman’s ability to consent to sexual relations.

Palliative care, whether provided in an institutional or community setting, does provide opportunity for attention to ensuring a patient’s capacity for sexual function and fulfillment of sexual needs. Palliation for sexual function could entail providing estrogen and/or testosterone therapy to a patient even if she has a history of an estrogen-sensitive cancer. It could also involve treatment aimed specifically at alleviating nonhormonal causes of dyspareunia. While many patients bring closure to their sexual lives before entering palliative care, it is not uncommon for a patient and her partner to wish to remain intimate as long as possible. Optimization of sexual function for middle age and older women in palliative care is understudied and often overlooked in clinical care, but is an area of increasing attention.

Sexual Partnership

Population-based normative data for older women show that sexual activity is largely determined by availability of a sexual partner. Among women aged 57 to 64 in the 2005–2006 NSHAP study, about 85% had a current spouse or other romantic or intimate partner. Nearly all of these relationships were reported as heterosexual, monogamous, and involving sexual activity. The proportion of women with a partner declined with age, because of earlier male mortality. By age 85, only about 40% of women had a partner, and fewer than 20% of all women engaged in sexual activity.

As compared with findings for younger women, women 57 years and older reported fewer total sexual partners over the lifetime. Most sexually active older women reported that their current relationship was monogamous. Nonmarried women with a partner were significantly more likely to report that their partner had other sexual partners during the relationship. In the NSHAP baseline study, nearly 1 in 10 married women and twice as many nonmarried women with a sexual partner believed that their current partner had other sexual partners during the relationship.

In the NSHAP baseline study, 5% of women reported ever having a female sexual partner and only five women (0.3%) reported currently being in a relationship with another woman. Although population data on lesbian relationships at older ages are only just beginning to emerge, estimates from the younger population suggest that women in this study may have underreported same-sex relationships. Qualitative research and clinical experience reveals cases of older women choosing or demonstrating receptivity to intimacy with female partners for the first time in later life. Some women explain this as a choice caused by the scarcity of males in later life, while others are fulfilling, for the first time, a lifelong interest. The Caring and Aging with Pride study, a national community-based study (2010) of lesbian, gay, bisexual, transsexual (LGBT) aging, found that among individuals older than 50 years, lesbian and bisexual adults were less likely to have a partner or be married than people identifying as heterosexual.

The low representation of sexual minorities in studies of older adults, the frequent exclusion of older adults in studies of sexual minorities, and the lack of inclusion of questions ascertaining sexual orientation in routine research practice render older LGBT adults largely invisible in most research. This invisibility is perpetuated in clinical settings when providers do not ask about sexual orientation and when patients feel unsafe disclosing their sexual orientation. Further research is necessary to understand the barriers to accessing care and the health needs of aging sexual minorities so that culturally competent care and targeted interventions can be delivered. With marriage equality declared a constitutional right, we expect that older adults who identify as members of a sexual minority group will be more likely to disclose their status in research, clinical, and institutional living settings.

Sexual Activity

Among those who are sexually active (defined in the NSHAP study as engaging in “any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs” during the prior 12 months), the kinds and frequency of sexual activity in which women engage are similar to those observed among younger women. Most commonly, sexual activity involves vaginal intercourse, hugging, kissing, or other forms of sexual touching, and about 45% of sexually active women engaged in oral sex. On average, the frequency of sexual activity for those with a sexual partner ranges from one to three times per month. This frequency is similar to that observed among younger sexually active adults. About a quarter of women aged 57 to 85 reported masturbating in the previous year. The prevalence of masturbation among women without a partner is the same as among women with a partner. This is also true for older men (50% report masturbating) and suggests that older adults maintain an individual desire for sexual activity, even in the absence of a sexual partner.

Sexually Active Life Expectancy

Sexually active life expectancy projects population patterns of sexual activity to estimate the number of years, for any given age, of expected future sexual activity. As calculated based on 1995–1996 and 2005–2006 data, at age 55, sexually active life expectancy is about 16 years for women with a spouse or other intimate partner (Figure 41-3). Among sexually active women, good health was associated with a gain of 3 to 6 years of expected future sexually active life. Communication of normative expectations to patients about the longevity and quality of their sexually active lives assuming good health could motivate patients to stop smoking, adhere to medication regimens, exercise regularly, or engage in other health-promoting behaviors. Further research is needed to evaluate the potential impact of sexually active life expectancy projections on individual health behavior. The sexually active life expectancy measure also quantifies years of sexually active life lost in the absence of knowledge and treatments to preserve sexual function as people age.

Sexual Problems

Among sexually active women, approximately half reported having one bothersome sexual problem; almost one-third reported having two. The most common sexual problems experienced by older women are summarized in Table 41-3. Lack of interest in sex, pain with intercourse, unpleasurable sex, and inability to experience orgasm are much more common among older women as compared to men and somewhat more common compared to younger women. Of course, some proportion of sexually inactive women discontinued sexual activity as a result of bothersome sexual problems and, therefore, the NSHAP baseline study underestimates the prevalence of problems in the whole population. On the other hand, many women engaged in sex despite bothersome problems. The rewards or gains of sexual engagement may outweigh the experience of sexual pain or lack of physical pleasure; some women may obligatorily participate in sex to satisfy their partner while others may lack agency to refuse.

In a 2006 mail-based survey (N = 31,581; 63% cooperation rate) referenced in the 2011 American College of Obstetrics and Gynecology Practice Bulletin on Female Sexual Dysfunction, Shifren and colleagues ascertained sexual problems and distress among sexually active and inactive women, including more than 6000 women aged 65 and older. The overall prevalence of sexual problems among all women 65 years and older was higher than reported by NSHAP (NSHAP estimated the prevalence of problems only for women who were sexually active) and the proportion of women who were distressed by these problems was substantially lower.

Problems related to sexuality in later life, including female sexual dysfunction, can result from sexually transmitted infection, trauma, and sexual violence or abuse. These topics are discussed below. Sexual dysfunction, including clinical diagnosis and treatment, is discussed in more detail later in this chapter.

Sexually Transmitted Infections

Data from the NHANES and the baseline NSHAP study provide the population prevalence of STIs among older women. Overall, the prevalence of most STIs in the general older adult population is very low (<1% for Chlamydia trachomatis, Neisseria gonorrhea, and syphilis), although rates of some infections may be higher in residential communities or geographic regions with high concentrations of sexually active older adults (eg, Florida and Hawaii in the United States), or in other subpopulations. A prevalence estimate for Trichomonas vaginalis among older US women is not available; late twentieth-century data from Danish and Chinese epidemiologic studies indicate that very few cases occur among women older than 60 years. Changes in the cervical epithelium caused by loss of estrogen in older women may account for reduced susceptibility to these infections. Although there is no evidence for an epidemic, STI prevalence among older adults is likely underestimated because of lack of uniform tracking systems and underidentification in the clinical setting. One study showed that physicians were more likely to counsel older African-American and married women about human immunodeficiency virus (HIV) and other STIs, but the majority of older women reported that a physician has never initiated such discussion.

Viral infections, including genital herpes simplex virus (HSV) and human papillomavirus (HPV), are among the more prevalent STIs among older women. HSV-2 seroprevalence among men and women 70 years and older based on NHANES III data (1988–1994) was 28%, but women had a higher overall prevalence than men and rates were much higher among African Americans (74%) and Mexican Americans (45%). High-risk, or oncogenic, HPV (HR-HPV) prevalence among women aged 57 to 85, based on 2005–2006 NSHAP data, was 6% and did not vary significantly across age or racial/ethnic groups. The prevalence of HR-HPV among older women is similar to that documented by NHANES for women aged 50 to 59. HR-HPV is an important factor in both cervical dysplasia and cervical cancer, a leading cause of female cancer death in the world. In the United States, about 20% of cervical cancer cases, but more than a third of cervical cancer deaths, occur in women aged 65 and older. Most screening and prevention strategies, including HPV vaccine, use age-based eligibility criteria that exclude older women.

The rate of new HIV infection among older women in the United States, particularly those of minority racial and ethnic groups, has been increasing over the last several years, due mostly to transmission by heterosexual sex. Mucosal atrophy (vaginal, rectal) related to menopausal estrogen depletion increases an older woman’s susceptibility to mucosal tears and abrasions that can facilitate HIV transmission. In 2010, 27% of Americans diagnosed with HIV/AIDS after the age of 50 were women. Public health messages regarding HIV/AIDS prevention and detection do not target older women, and physicians rarely offer HIV counseling or testing to this group. The effects of HIV/AIDS and treatments on sexual function among older women have been minimally investigated. Please see Chapter 128 for further discussion of HIV in later life.

STI prevention strategies have not been well-tested for older adults. Few older adults, including those in nonmarital sexual relationships, report using condoms. Condom use by older couples to prevent STIs may be compromised by similar knowledge, communication, behavioral, and cultural barriers experienced by younger couples; by the belief that condoms are not necessary if there is no risk of pregnancy; and by changes in male and female physiology that occur with age. A male condom is best applied when the penis is fully erect, but for some older men, full erection may not occur until after coitus is initiated. Female condom use does not require a fully erect penis and may be preferable for some couples. For women, increased susceptibility to condom-induced vaginal irritation or abrasion may result from vaginal dryness and/or atrophy caused by estrogen depletion.

Counseling women with new or multiple sexual partners warrants attention to prevention of STIs, including discussion of barrier methods such as male and female condoms and dental dams (for oral sex) (Figure 41-4). Couples receptive to using condoms should be taught proper application, encouraged to use foreplay to encourage full penile erection and maximal female arousal before penetration, and counseled to consider water-based lubricants (oil-based lubricants can reduce condom effectiveness; to reduce vaginal and vulvar friction. Condoms with spermicide are not necessary for postreproductive age women and should be avoided because they have a shorter shelf-life and have been associated with urinary tract infection in younger women. Nonlatex male and female condoms and dental dams are available for individuals with latex sensitivities and allergies, and they have physical and performance properties that some individuals may prefer. Male and female condoms and dental dams are for one-time use only.

The 2010 US Patient Protection and Affordable Care Act covers annual wellness visits that include a physical examination and health risk assessment for Medicare beneficiaries. While these visits are an ideal opportunity for physicians to assess their patients’ sexual history, sexual history-taking is neither included in the CMS quick reference document for the annual wellness visit nor the Centers for Disease Control and Prevention’s (CDC’s) more comprehensive framework for patient-centered health risk assessments. Medicare does cover HIV testing, and, for at-risk individuals, chlamydia, gonorrhea, syphilis, and hepatitis B tests. People at increased risk of STIs can receive up to two individual 20- to 30-minute, intensive in-person behavioral counseling sessions each year. These counseling sessions can include education, skills training, and guidance on safe sexual behavior and may help mitigate the competing clinical issues that prevent discussion of safer-sex practices during routine visits.

Sexual Trauma, Violence, and Abuse

Early life events, including sexual trauma in the form of abuse, exploitation, genital injury, and rape, can have lasting effects on sexuality and health that persist into later life. Lifetime estimates among older women indicate that 20% to 26% of women experience intimate partner violence; nearly 40% in one study reported that this was severe, including forced sex or sexual contact. In the NSHAP baseline study, 9% of women aged 57 to 85 reported a lifetime history of forced sex (which may or may not have been with an intimate partner); of these, nearly 40% reported that the most recent event occurred at or younger than age 19 and 16% reported that the most recent event occurred after age 40. Sexual dysfunction, particularly conditions such as vaginismus, dyspareunia, inability to experience orgasm, lack of pleasure with sex, and disturbing fantasies are more common among women with a history of sexual trauma, violence, or abuse. In conjunction with medical treatment and/or physical therapy, psychotherapy including cognitive-behavioral techniques and strategies used for treatment of posttraumatic stress can be effective in helping women at any age cope with sexual violence and experience positive sexual relationships.

Elder mistreatment, or abuse, discussed in Chapter 54, is defined by the US CDC to include sexual abuse or abusive sexual contact but is not limited to an intimate partner. In fact, lack of a spouse or other partner, cognitive impairment, and institutionalization are risk factors for female sexual abuse and rape in later life. Very little is known about how commonly older women experience sexual violence or abuse; 3% of women aged 60 and older in one study reported having been pressured to have sex in a way they did not like or want since age 55. Few older women report that a physician has ever asked questions to ascertain sexual victimization. There is not sufficient evidence to support the accuracy of existing screening tools to identify abuse in older adults, and studies of interventions to address sexual trauma focus almost exclusively on younger women, perhaps explaining why physicians may feel ill-prepared to screen for victimization among older women. Screening questions for identifying intimate partner violence in the clinical setting are summarized in Table 41-4 and should be part of routine assessment of the older woman.

Consideration of intimate partner violence and sexual abuse in the acute or emergency care settings should be given, particularly when a woman presents with physical injury, vague symptoms (especially in recurrent visits), acute mental status changes, and/or is accompanied by a partner or other individual who interferes with the patient’s interaction with health care providers.

The female sexual response cycle provides one simplified framework for understanding and remembering domains of sexual problems experienced by women. The Masters and Johnson model of the female sexual response cycle (Figure 41-5A), based on physiologic research initiated in the 1960s with a convenience sample of local sex workers, other volunteers, and patients presenting for treatment of sexual problems or contraception, remains the most widely represented model in medical textbooks and until recently was the foundation for the Diagnostic and Statistical Manual definitions for sexual dysfunction. This traditional, linear model describes four phases of human sexual response: excitement, plateau, orgasm, and resolution (sex therapist Helen Singer Kaplan modified this in 1979 to include orgasm, excitement, and desire) and illustrates notable differences in female as compared with male sexual physiology.

According to Masters’ and Johnson’s work, the female sexual response is more variable than that of males, and female orgasm may be single and peak-like similar to male orgasm, more gradual or undulating, and/or repetitive during a single sexual encounter. The typical male sexual response is described as much more uniform, peaking in a single orgasm, and includes a latency period during which a subsequent orgasm cannot occur. Arousal for women tends to require tactile stimulation, otherwise known as foreplay. Many women require direct clitoral or periclitoral stimulation before, during, and/or after intercourse (which may involve penile-vaginal, penile-anal, oral, or manual penetration) in order to experience orgasm. This may be particularly important for older women engaging in vaginal intercourse with male sex partners because of reduction in the firmness and fullness of the male erection in later life.

The pattern of female sexual response may vary across time within a single relationship or with different sexual partners, although little is known empirically about the physiology of the female sexual response cycle in later life or in the context of very long-term (several decades or more) relationships. Psychoemotional changes, and changes in physical appearance with age including appearance of the vulva and breasts, can negatively or positively affect an older woman’s feeling of attractiveness, and can influence her interest in sex. Some women indicate decreased psychological inhibition about physical appearance or improved self-image with age, both of which can be sexually liberating.

Changes in men’s sexual response that occur with age can affect female partners both physically and psychologically. As men age, the sexual response becomes more similar to that of women (a phenomenon some refer to as “feminization of the male sexual response cycle”). Tactile stimulation and foreplay are increasingly important for older male arousal, the time to erection and orgasm is longer, and latency between orgasms (the refractory period) is increased. Because few older men or women are aware of these phenomena, these changes are often perceived as abnormal, cause unnecessary anxiety and shame, and can strain both members of a couple. Some couples cease sexual activity as a consequence and most do not seek medical help. Some couples find benefit in the changes to sexual physiology that occur with age. For example, the mutual need for foreplay and the longer arousal phase in men allows, for some couples, the more frequent pleasure of simultaneous orgasm. Older women and their partners should be provided basic information about the normative changes to sexual function that can occur with aging. The National Institute on Aging offers an “AgePage” on this topic (http://www.nia.nih.gov/health/publication/sexuality-later-life); the American Association of Retired Persons (AARP) also offers accessible, consumer-focused information about sexuality and intimacy in its publications.

Building on the pioneering work of Masters and Johnson, Basson proposed a widely referenced intimacy-based, cyclical model of the female sexual response that incorporates the quality and duration of the relationship as well as the psychoemotional component of female sexuality (Figure 41-5B). In older and younger women, sexual desire may occur before or following sexual arousal. This model emphasizes the role of intimacy in generating female sexual desire and suggests that lack of intimacy and unsatisfying sexual encounters can raise the threshold for interest and arousal in a subsequent sexual encounter. Rather than linear and discrete, the phases of the female sexual response are described by Basson as variably overlapping in a way that “blends mind and body.”

Further empirical characterization of the physiology and psychosocial aspects of the female sexual response cycle in later life, including how it might fluctuate within relationships over long durations of time, across relationships, and with aging, is needed both to inform women’s expectations and the clinical approach to older women’s sexuality.

Effects of senescence on the endocrine, neurovascular, musculoskeletal, genitourinary, and gastrointestinal systems are particularly salient to sexual function in later life. More global changes in physical appearance, sensory function (hearing, vision, olfaction, taste, and tactile sensation), cognitive function and memory, and body aromas such as scent, breath, and genital odor can also affect sexual engagement and enjoyment. The female sexual response involves a complex and highly interconnected series of physiologic events connecting mind and body. Disruptions or changes in any of these physiologic systems caused by age-related changes, physical or mental illness, or medical procedures and medication use can alter the sexual response and the ability of a woman to derive pleasure and satisfaction from her sexual encounters.

Endocrine System

Loss of estrogen as a result of menopause is a dominant physiologic event that can affect many aspects of older women’s sexual function. Despite extension of the human lifespan, the age of menopause has not changed. Women can live a third or more of life in menopause: the median age of natural menopause in the United States is 51.3 and average female lifespan is 81.1 years. Surgical menopause occurs when a woman undergoes bilateral oophorectomy (or loses ovarian function as a result of other interventions such as chemotherapy or radiation) prior to natural menopause. In the NSHAP study, about one in five US women aged 57 to 85 reported a history of surgical menopause. Women who have undergone bilateral oophorectomy, pre- or postmenopause, also experience an abrupt and irreversible loss of androgen production.

Estrogen is important for maintaining skin, subcutaneous, mucosal (vaginal, bladder, and rectal) and musculoskeletal integrity, the vaginal microenvironment (pH balance and microflora), vascular flow to the vagina and clitoris via regulation of nitric oxide synthase expression, and sensory perception. Over time, in the genital tract, low estrogen results in vaginal dryness, loss of epithelial cell glycogen, shortening of the vagina, narrowing of the introitus, thinning of the labia, and diminution of the fat pad underlying the mons pubis (Table 41-5). Loss of vaginal acidity results from glycogen depletion and can increase propensity for bacterial vaginitis. Urinary and fecal incontinence can be exacerbated by estrogen depletion and inhibit social and sexual relationships as well as sexual function. Maintenance of sexual activity in later life appears to offset some of these local genital changes, in part by maintaining elasticity of the vulvovaginal tissues, pelvic floor musculature, and pelvic joints. Additionally, sexual activity and other forms of physical contact may mitigate estrogen-related decline in sensory perception and function with age and may play a role in female attractiveness. Exogenous estrogen is approved by the US Food and Drug Administration (FDA) for treatment of moderate to severe dyspareunia in women. Ospemifene, a selective estrogen reuptake modulator (SERM), has also been approved for the same indication but is not yet widely used in the United States. Largely owing to highly publicized findings from the randomized, controlled hormone therapy trials of the US Women’s Health Initiative Study (comparing use of combination equine estrogen alone or in combination with progesterone to placebo among postmenopausal women aged 50–79 at baseline), a minority of women currently use prolonged estrogen therapy for treatment of menopausal symptoms or preservation of sexual function.

Testosterone, along with dehydroepiandrosterone (DHEA), plays an important role in female libido, arousal, genital sensation, and orgasm. Loss of testosterone can exacerbate vaginal mucosal atrophy, thinning of pubic hair, and may compromise an older woman’s sense of general well-being. Female androgen insufficiency as a treatable condition or syndrome is controversial. While levels of endogenous androgens have not been found to be predictive of sexual function, testosterone therapy for low libido has been shown to be effective in clinical trials involving women with bilateral oophorectomy or total loss of ovarian function, as well as postmenopausal women on estrogen therapy (estrogen reduces bioavailable testosterone by increasing sex hormone–binding globulin production). However, the FDA has not approved testosterone for this indication. Use of testosterone or DHEA to treat female sexual dysfunction is currently off-label in the United States and most countries, and requires close monitoring for side effects. Although rare, irreversible deepening of the voice and growth of facial hair may occur with testosterone use.

Figure 41-6 summarizes central and peripheral hormonal mediators of sexual function (see also Chapter 108). Understanding centrally mediated neuroendocrine changes that occur with senescence is an active area of discovery, focused heavily on understanding cognitive pathophysiology. In women and female animal studies, interest in the cascade of neuroendocrine events resulting in menopause has been similarly driven by an effort to understand the role of sex hormones and hormone therapy in neuroplasticity and degeneration, as well as by efforts to treat female infertility. Application of this knowledge to female sexual function in later life, particularly sex differences in endocrine regulation of the sexual response cycle, is nascent.

Aside from its peripheral effects, estrogen plays an important central role via direct membrane receptor activity and modulation of neurotransmitters. Estrogen appears to exert neurotrophic and neuroprotective activity in the brain that mitigates hypothalamic damage that occurs with age. Estrogen also interacts with serotonin and norepinephrine metabolism, which may explain the role of estrogen depletion in sleep, mood, memory, and, through these and no doubt other mechanisms, the female sexual response cycle in later life.

The hypothalamic-pituitary-adrenal (HPA) axis mediates the human physiologic stress response and, of course, is the pathway or pacemaker through which sex hormonal regulation occurs. The loss of temporality and pulsatility in HPA neural signaling is a key event in menopause; the dynamics of HPA function over the portion of the lifespan following menopause and the implications for female sexual functioning in later life are much less well-defined. Vasoactive intestinal peptide (VIP), now recognized to play a role in female sexual arousal via vasocongestion of the clitoral tissue, also signals time of day information for central gonadotropin-releasing hormone (GnRH) regulation. Rhythmic synthesis of VIP in the brain appears to wane by middle age in women and may be an important triggering event in the loss of hypothalamic-pituitary-ovarian access coordination required for ovulation and menstruation. The peripheral effects of changes in central VIP metabolism for later life sexual arousal in women are unknown.

Neurovascular System

Neurovascular physiology, mediated by the sympathetic and parasympathetic nervous systems and a growing list of nonadrenergic/noncholinergic neurotransmitters (eg, nitric oxide and VIP), is particularly important for the arousal and orgasm phases of the female sexual response cycle. Arousal involves vascular engorgement of the genitopelvic organs, including the labia, vagina, and clitoris; lengthening, dilation, and lubrication of the vagina; retraction of the clitoral hood; and tumescence of the clitoris. Microvascular integrity is important for genital sensation and orgasm. Clitoral sensation, in particular, can be compromised by microvascular disease as seen in chronic smokers and women with hypercholesterolemia or diabetes. Although clinical guidelines for diabetes care in men advise assessment and treatment of erectile problems, clinical guidelines for women do not go beyond screening for sexual dysfunction. Research on effective treatment options for sexual dysfunction among older women with diabetes is needed to inform clinical guidelines. Women with diagnosed diabetes are less likely than men to have discussed sexual problems with a physician and more likely to cease all sexual activity.

Cardiovascular disease can impair women’s sexual function in later life both through psychological and physiologic mechanisms. Although practice guidelines recommend that physicians communicate with patients about the sexual implications of heart disease and potential sexual side effects of treatment, these issues are commonly omitted from counseling, and men are significantly more likely than women to receive such counsel.

Treated and untreated hypertension are both associated with lower rates of sexual activity among older women. However, among sexually active older women, the rate of sexual problems is similar among women with treated hypertension, untreated hypertension, and no hypertension. No one class of antihypertensives has been consistently associated with female sexual dysfunction, particularly in older women. Based on expert opinion, older women with hypertension should be counseled that treatment of hypertension is likely to improve overall sexual function and longevity.

Acute myocardial infarction (AMI) is the leading cause of death among middle age and older women; approximately 40% of all AMIs in the United States occur in women. US and European practice guidelines state that patients with uncomplicated AMI can resume sexual activity within a week of AMI. Based on the largest study to date of sexual outcomes in AMI among older women, the majority of those who were sexually active before their AMI resume sexual activity within 1 year following AMI. Receipt of counseling by a physician about resuming sex is the single most important predictor of whether a woman resumes sexual activity after AMI.

Phosphodiesterase inhibitors are used in men to treat neurovascular causes of erectile dysfunction; similar effectiveness has not been found in women. The only FDA-approved device for treatment of female sexual dysfunction, the Eros Therapy (UroMetrics) clitoral pump, may assist some women with microvascular disease in experiencing improved clitoral sensation, vaginal lubrication, and orgasm.

Musculoskeletal System and Body Fat

Parity, childbirth-related injury, pelvic or lower extremity trauma, obesity, and sedentariness can compromise the integrity of the vulvar, pelvic floor, and lower extremity musculature, contributing to incontinence and pelvic organ prolapse. Effective contraction and relaxation of the peri-introital, perineal, and pelvic floor muscles are important for penetration, arousal, orgasm, and the relaxation phase following orgasm. Loss of flexibility of hip muscles and compromised stability and mobility of hip joints, commonly experienced by women with arthritis or hip fracture, can interfere with sexual functioning in later life. Skeletal changes in the hips and vertebrae caused by loss of bone density, osteoporosis, vertebral compression and fracture, and arthritis can make vaginal penetration, particularly using “missionary” (female supine with hips and knees flexed) position, difficult and may be accommodated by use of alternative sexual positioning such as side-lying or sex without vaginal penetration. Prevention and treatment of these conditions with attention to maximizing musculoskeletal strength and flexibility can improve overall physical functioning and help preserve sexual capacity for aging women. Endorphin release associated with pleasurable sexual activity may help alleviate musculoskeletal pain.

Although more than a third of women older than age 65 are obese, little is known about the effect of obesity on older women’s sexual function and satisfaction. Research is further complicated by women’s varying self-appraisals of their body size and attractiveness, the frequent co-occurrence of obesity and chronic disease among older women, and the potentially different contributions of abdominal adiposity, generalized obesity, and relative weight gain post-menopause.

Genitourinary System

Changes in the genitourinary system are heavily influenced by postmenopausal loss of estrogen. The urethral orifice can become everted and sensitive to friction, which may cause pain during penetration. Laxity in the pelvic tissues can result in prolapse of the uterus and vaginal walls (ie, cystocoele, rectocoele, enterocoele). Cervical contact with sexual penetration can cause an “electric shock” or otherwise painful sensation during vaginal intercourse and limits the depth and force of penetration. Cervical prolapse that is visible at the introitus or procidentia (prolapse through the vagina) can make vaginal intercourse very difficult or impossible. Urinary incontinence and/or the fear of losing urine during intercourse or orgasm can cause avoidance of intercourse and difficulty with orgasm. Pessaries may be used to reduce prolapse and treat urinary incontinence; some, such as ring pessaries, are designed for compatibility with intercourse but should be removed and cleaned following intercourse. Procedures to treat pelvic organ prolapse and urinary incontinence may improve sexual functioning for some women, but colpocleisis (partial or total surgical closure of the vagina to treat prolapse) is largely prohibitive for penetrative vaginal sex.

Gastrointestinal System

Gastrointestinal changes with aging that are most relevant to female sexual function include incontinence of stool and flatus, hemorrhoids, and borborygmi. Anal or stool incontinence, commonly overlooked, typically results in cessation of sexual activity and can be very socially isolating. Hemorrhoids can be exacerbated by sexual activity, particularly anal intercourse, and may result in bleeding during or following sex. Borborygmi can be controlled to some degree by timing of meals in relation to symptoms. Older women who have ceased and/or who wish to resume sexual activity after a hiatus should be screened and evaluated for both urinary and anal incontinence and treated in order to prevent embarrassing or painful sexual experiences that can be very detrimental to sexual self-image and function. Constipation can be a cause of dyspareunia; this can be overcome by treating the primary cause of constipation and educating the patient to time sexual activity after moving her bowels.

Cancer and Female Sexual Function

The vast majority of cancers affecting older women involve treatment with local or systemic therapies that impair or surgically remove the sexual organs. The majority of women, at all ages, who develop cancer value their sexual function and wish to preserve the possibility of future sexual activity. All women, regardless of age or current partner status, undergoing treatment for cancer should be counseled about the potential effects of cancer or its treatment on future sexual function, and baseline sexual activity and function (prior to cancer treatment) should be documented. Women undergoing pelvic radiation should be offered vaginal dilation therapy to preserve vaginal capacity for sexual activity and future gynecologic examinations. The most common sexual function problems in this patient population include dyspareunia, commonly resulting from or exacerbated by severe vulvovaginal atrophy, and diminished or no libido. Compromised sexual function and painful or unsatisfying sexual activity may strain intimate partnerships and provoke anxiety about cancer recurrence. Repeated studies show that women with cancer, including older women, believe that physicians should discuss sexual outcomes and side effects of treatment. As in cardiovascular disease, women who report discussing sex with a physician are significantly less likely to avoid sex because of a sexual problem or to exhibit complex sexual morbidity.

There is ample evidence that older women, including those who are not currently sexually active, regard sexual function as an important aspect of health, believe it is appropriate for physicians to discuss sexual issues in the context of medical care, and want physicians to be proactive in counseling about sexual outcomes or side effects of treatment. There is simply no evidence to suggest that appropriate attention to female sexual function in the context of medical care, including geriatric care, causes patient harm or other negative outcomes. To the contrary, avoidance of these matters can be deleterious, particularly for women who identify as a member of a sexual minority group. Geriatricians can signal their openness to all patients by posting commonly recognized symbols such as a rainbow flag or an explicit statement of respect for all human rights (Figure 41-7).

Table 41-6 lists basic sexual history questions that can be incorporated into a routine geriatrics encounter and should be tailored to the individual’s needs.

The geriatrician is also encouraged to include on patient self-report or review of system checklists a simple item such as, “Do you have any sexual problems or concerns?” The widely used PLISSIT model or the “therapeutic moment” approach described in Tables 41-7A and B can help guide a preliminary conversation about sexual concerns. When a patient presents with multiple concerns in addition to a sexual concern, the geriatrician should work with the patient to prioritize issues for the current visit, acknowledge the sexual concern, and suggest, if necessary, that the patient return for a visit focused specifically on that issue. The IBM (see Figure 41-1) provides a useful framework for more in-depth assessment of a patient’s sexual concern. The geriatrician should inquire about the patient’s biological or medical problems, psychological or emotional problems, and relational or social problems. If the patient is in a current relationship, the history should also inquire about the partner’s health in these domains, whether there has been communication with the partner about the patient’s sexual concerns, and whether the partner also has any sexual function difficulties.

Use of terms like “dysfunction,” “normal,” and even “healthy” in relation to human sexuality requires caution and has been criticized, particularly in the feminist and psychology literatures. What is a normal level of sexual desire for older women? Is celibacy unhealthy? Few older women report same-sex partners, so is lesbianism abnormal? Is a distressing sexual difficulty a “dysfunction” or a “normal” response to unhappy circumstances in a relationship? Critiques are rooted in a painful history of sexual discrimination, particularly in the United States, and partially in medical history; as recently as the early 1990s, female sexual dysfunction could be diagnosed as a sexual problem experienced by a woman even if it was only troublesome to her partner. In addition, skeptics of the “medicalization” of female sexuality question how “normal” or “functional” sexuality can be defined as the absence of problems, given the high prevalence of sexual problems in the population.

Diagnostic Classification of Female Sexual Dysfunction

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) updates classification of female sexual dysfunction for clinical diagnosis (Table 41-8). The DSM-5 merges the conditions dyspareunia and vaginismus (classified separately in the DSM-IV) as genitopelvic pain/penetration disorder. Hypoactive sexual desire disorder and female arousal disorder are now defined as female sexual interest/arousal disorder.

Population estimates of sexual problems from the cross-sectional NSHAP study (Figure 41-8) and other studies are useful for quantifying the baseline prevalence of sexual problems in later life, or even bothersome sexual problems, but should not be expected to translate precisely into population rates of female sexual dysfunction, clinically defined. Prevalence estimates for older women can be estimated from prior studies, but are needed for the newly defined classes of genitopelvic pain/penetration disorder and female sexual interest/arousal disorder.

Causes of Female Sexual Dysfunction

Sexual dysfunction in later life can be primary, such as a lifelong history of bothersome low sexual desire, or secondary. Secondary causes include (1) interpersonal and personal psychological factors including depression and substance use, (2) biological factors including a wide spectrum of illnesses, injuries, physical disabilities, and their medical and surgical treatments (note that earlier life illness such as cancer and its treatment have been shown to have long-lasting effects on sexual function in survivors), and (3) social factors. The patient’s psychosexual history and her current partner’s physical and mental health, medication, and substance use and sexual function must also be investigated in order to gain a full picture of the patient’s sexual functioning and to appropriately tailor therapeutic interventions. Common medications implicated among iatrogenic causes of sexual dysfunction are summarized in Table 41-9. Evidence for the effects of drugs on sexual dysfunction is mixed overall and very limited with respect to older females, specifically. Treatment of underlying disease and health concerns, including common problems like incontinence, vaginal atrophy, sleep dysfunction, and depression, is an essential first step to addressing sexual function problems. Sexual side effects of medications can be offset by improvement of disease-related symptoms and better overall health.

Clinical Evaluation of Sexual Dysfunction

Questions to assess sexual dysfunction are summarized in Table 41-10. Identification of the level of personal distress caused by each problem can be assessed informally by asking, “How much does this problem bother you?” and can be noted as a lot, somewhat, or not at all. Not uncommonly, an older woman will say she is not bothered by the problem, but is motivated to address it for relational purposes. A validated instrument, the Derogatis Female Sexual Distress Scale (2002), can be used to track change in distress over time, but is primarily a tool for research purposes and has not been validated in geriatric-age women. Many other research tools have been developed to track female sexual function over time. Few have been validated in older women. We recommend the PROMIS sexual function measures developed with funding from the US National Cancer Institute (http://www.nihpromis.org/measures/availableinstruments).

Although many adult female sexual function problems have a psychosocial component, a physical examination is needed for thorough evaluation and treatment. The physical examination should include examination of the inguinal lymph nodes, perineum, vulva, vagina, internal reproductive organs, anus, rectum, rectovaginal septum, and pelvic floor musculature. A vulvar cotton swab test can be used to quantify and localize vulvar pain. Graded vaginal dilators can be used to demonstrate to the patient her vaginal capacity and to educate her about dilation, a useful modality in women seeking to resume sexual intercourse after a long hiatus, in women with vaginal stenosis related to radiation or extreme atrophy, and in women with vaginismus. Using a hand mirror during the pelvic examination allows the patient to visualize genital findings and the depth of penetration with the examining finger, speculum, or a vaginal dilator. This information can be therapeutic and facilitate education about the patient’s genital anatomy and any physical findings.

Details of the routine gynecologic examination can be found in Chapter 42. The geriatrician or gynecologist should be prepared to provide accommodations for older women undergoing a gynecologic examination such as alternatives to the dorsal lithotomy position; a small-sized, warm, Pederson-type speculum with ample lubricant; extra padding and pillows on the examination table; lower or electric examination tables with padded stirrups. Under the Americans with Disabilities Act of 1990, medical care providers must examine patients with disabilities as they would any patient, and if a medical provider cannot provide an examination table that a patient can access, they must provide assistance to help patients onto the examination table including assisting with transfer if necessary. Patients may be examined in a wheelchair if they wish, although they should be advised that this evaluation is suboptimal. The physician should assure the patient that the patient is in control and the examination can be stopped at her will.

Clinical Management of Female Sexual Dysfunction

Although the evidence base for treatment of sexual problems in women is growing, few studies to date include women older than 65 years. Treatment of many sexual problems benefits from an interdisciplinary approach when possible, including thorough medical evaluation, and in some cases, physical and/or psychotherapy. The 2008 US Medicare Improvements for Patients and Providers Act aims to improve coverage of mental health services for Medicare beneficiaries, which could benefit women with sexual dysfunction and comorbid depression or other mental health issues, although very few mental health professionals with expertise in geriatrics are also certified in sex therapy. The overview of clinical management presented here draws heavily on recommendations by Basson et al. (2010) from the 2009 3rd International Consultation on Sexual Medicine convened by the International Consultation on Urological Diseases and the International Society for Sexual Medicine and uses DSM-5 classifications. It aims to give primary care providers initial treatment options. If available and affordable, referral to a specialist with experience in treatment of female sexual dysfunction may be optimal. Psychotherapy, including couples’ and sex therapy, cognitive-behavioral approaches, and sensate focus techniques have long been implemented for treatment of female sexual dysfunction and can be adapted to the needs of older women and couples.

Genitopelvic Pain/Penetration Disorder

Genitopelvic pain/penetration disorder is more common during and after menopause, exacerbated by thinning of the vaginal mucosa, decreased vaginal lubrication, prolapse of the pelvic organs, and shortening of the vagina caused by natural or iatrogenic loss of estrogen. Pain is a common reason for cessation of sexual activity among older women and couples. Management involves treatment of the underlying condition. Conjugated equine estrogen and, more recently, ospemifene (a SERM) have FDA approval for treatment of moderate to severe dyspareunia caused by vulvovaginal atrophy in menopausal women. For women who cannot or who prefer not to use estrogen or SERM therapy, over-the-counter vaginal moisturizers used two or three times weekly over an extended period can reduce chronic vulvovaginal irritation and increase comfort with intercourse. Lubricants are typically used to reduce friction during vaginal or anal penetration in women with dyspareunia and are also available in hundreds of variations over the counter (Table 41-11). Pelvic physical therapy is an effective modality for treating dyspareunia when there is a pelvic, abdominal, and/or low-back component to the dyspareunia and when vaginismus is present. Vaginal dilation with graded dilators or other devices and behavioral, sex, or couples’ therapy are additional modalities that benefit many women with sexual pain disorders.

Orgasm Disorder

Management depends heavily on whether the disorder is lifelong or acquired and situational or generalized. Acquired situational orgasmic disorder is most common and occurs in the setting of decreased libido and/or relational strain. Because older women, particularly those 75 years and older, have less experience with masturbation (some report they have never masturbated), ability to assess orgasmic ability may be limited. Encouragement to self-stimulate either manually or with a vibrator, a technique sometimes used with younger women, must take into account the older woman’s experience and attitudes about masturbation. Psychotherapy to assess psychological issues and attitudes regarding orgasm and to complement physical interventions may be necessary. Education about vulvar anatomy, the role of the clitoris in orgasm, and variations in female orgasm may be therapeutic for some women. Women with arousal disorders also typically do not experience orgasm so evaluation of arousal should be included in women with this complaint. Sleep dysfunction is a common comorbidity in women with arousal and orgasm disorders.

Medical Therapy for Female Sexual Dysfunction

Currently there are two FDA-approved medical treatments for postmenopausal women experiencing sexual dysfunction, conjugated equine estrogen and ospemifene, as discussed earlier. Other systemic and local exogenous estrogen products, especially local vulvovaginal estrogen cream and vaginal estrogen tablets and rings, are commonly used off-label to treat dyspareunia in menopausal women.

Androgen therapy, including testosterone and DHEA formulations, is being used off-label in some cases for treatment of sexual arousal/interest disorder. Side effects can be irreversible and safety is not established in older women. Tibolone, a synthetic steroid hormone, has been investigated for the treatment of sexual dysfunction in postmenopausal women but evidence of its benefits is limited and it is not approved by the FDA. Treatment of depression can improve sexual desire and interest, but some antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), can inhibit sexual interest. There is limited clinical data to inform treatment options for SSRI-induced sexual dysfunction, but decreasing or ceasing the SSRI dose, switching antidepressants, or using bupropion in combination with SSRIs to offset this side effect may be effective for some women.

Off-label use of phosphodiesterase inhibitors has also been tried for women with genital arousal disorder (a very small subset of women with sexual dysfunction); again, safety has not been established in older women and there is no convincing evidence that benefit outweighs risk. Tricyclic antidepressants and anticonvulsants are being used by some practitioners for treatment of vulvovestibulitis (a cause of dyspareunia), but these should be used with caution because of central nervous system side effects that may be exaggerated in older women, particularly those taking other medications.

Funding for intervention research in the area of female sexual dysfunction comes primarily from pharmaceutical sources supporting clinical trials of small numbers of young, healthy subjects followed for brief periods; even studies of postmenopausal women include only small numbers of older women. Building an evidence base is a necessary step to offering safe and effective medical, psychological, and other treatments for female sexual dysfunction in later life. Several drugs for treatment of female sexual dysfunction, particularly sexual interest/arousal disorder, are currently in preclinical and clinical trials. The FDA has held a patient-focused drug development public meeting and scientific workshop on female sexual dysfunction to learn from patients about their perspectives on female sexual dysfunction and the treatments currently available. Of note, among men aged 57 to 64 surveyed in two nationally representative cohorts conducted 10 years apart, a greater proportion of men interviewed in the more recent cohort reported an increase in sex, perhaps because the later cohort was surveyed after highly effective erectile dysfunction drugs became available. This suggests that as more treatment options for female sexual dysfunction become available, an increase in sexual activity among women in later life may occur.

Older women comprise more than half the population of older adults in the United States and will outnumber older men through 2050. Nevertheless, many aspects of older women’s health are neglected by researchers and clinicians, including sexuality. Sexual and intimate relationships in later life can promote health and well-being and sustain a basic human need. Many older women engage in sexual relationships despite sexual problems and pain, while others discontinue sex caused by problems that could be treated. Physicians caring for older women can positively impact their patients’ sexual functioning and overall well-being by initiating and fostering an open and ongoing dialogue about sexual matters in the context of healthy aging or in relation to medical conditions and their treatments. Public health messaging and medical education addressing the continued importance of sexual health discussions past reproductive age could help normalize late life female sexuality and validate older women’s sexual health concerns. Research is needed to establish trajectories of older women’s sexuality with aging especially among people identifying with racial, ethnic, and sexual minority groups, and to provide an evidence base for diagnosis and treatment of female sexual dysfunction in later life.

We would like to acknowledge Amber Matthews, BA, and Isabella Joslin, BA, research assistants in the Lindau Laboratory at the University of Chicago, for their contribution to the review and synthesis of the literature. Additionally, we would like to acknowledge Amber Matthews for her work on data visualization, figures, and editing.