Finances & Lifestyles

Chapter 9

1. I.  Older People and Sex: 

   You may have read about Abraham Maslow in other courses but I think the theory warrants a review here since sexuality is very much related to life satisfaction. Sex is considered, by Abraham Maslow,to be one of our most basic human needs.  The link below is taken from the Sociology of Aging lecture and will enhance your understanding of this week's materials.

   Abraham Maslow's Theory

   "Sexual expression can be seen as a quality of life issue. Once survival needs are fulfilled, for example, for food and shelter, the needs for intimate relationships and feelings of being loved are vital. In fact, studies show that babies who are deprived of physical touch and emotional stimulation suffer serious gaps in emotional and physical development." Just put in the key terms babies, touch and study into any search engine to see all the work done on this topic.
   
   The need for intimacy does not change in old age. In fact, the desire for intimacy can intensify. As people lose their partners or peers they become attracted to others (remember a person’s self-concept remains intact by taking part in activities that mimic the activities of middle age). Relationships develop and sexual feelings may become activated. For many people, these feelings are a gift and bring a sense of pleasure and a feeling of being alive".
   
   Quoted from: Porter, Lisa and Douglas Holmes: Staff Educational Manual: Resident Sexuality In The Nursing Home,National Alzheimer Center of The Hebrew Home for the Aged At Riverdale, 2005.

   Our views of older people and sex are shaped by societal myths and stereotypes. These myths create sexual invisibility of older adults. 

   For example: how many of you can imagine your parents or even your grandparents engaging in sexual activity?  Did you get here by  immaculate conception? Probably not.  It's hard for us to imagine our parents or grandparents "DOING IT", yet studies show, that if an elder is healthy, and has a mate, a large majority of them remain sexually active in late old age. 

    

   • One of the first myths is that sex and being sexy are for young people and not older people. 
     When we are confronted with older adult's sexuality we think it is "funny or cute" for older people to have sexual interests and behaviors.
     
   • Older people who are sexually active are often labeled as weird or deviant (he's a dirty old man/she's 
     inappropriate or off in the head).
     
   • Many think that older people are unable to have sexual intercourse. There may be adjustments with aging especially if one of the partners has a disease such as dementia. 
     Check this site  http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=677

   Because of these myths people poke fun at sexual activities of older people or the supposed loss. Stand-up comedians make jokes about old age and sexuality. For example consider your supposition to this joke.
   

   It's a Fairy Godmother joke
   
   Two statues, one of an old  man and the other of an old woman, have been on an old building's entrance, facing each other for more than 100 years.
   
   They are granted the wish of being human for 30 minutes. So they jump down and rush into the bushes. 
   The bushes shake, rattle and roll. After a few minutes they come out. 
   
   The Fairy Godmother says, "You still have 10 minutes left." The old couple look at each other, and the man asks, 
   "Want to do it again?" The woman says, "Yes, but this time you hold down the pigeon and I'll poop on his head!

    

   Why is this joke funny? Would it be as funny if the statues were young Romans aged 19 or 20? Probably not. 
   

   Stereotypes of asexual behavior in older adults are ageist. These jokes affect older people. For example: older people seldom speak of enjoying sex for fear of ridicule.

           Misinformation about older people and sexuality is passed from one         
           generation to another. Today's older cohorts are         
           more private about their sexual expression than younger cohorts -- can you     
           imagine why?
   
           Older adults today were raised during a time when sexual expression was not 
           talked about openly. This attitude is left over 
           from repressive Victorian era (remember the  society of women who  
           proposed putting clothes on the legs of tables ?)
   

   Inability to talk openly about sexuality results in little information regarding sexuality,  how to express one's self, or what to  expect in terms of performance in later life.

   
   
   II. Sexuality as More Than Just Physical Contact - (Intercourse)
   "First, we should keep in mind that sex is not only a biological drive for pleasure and reproduction. It is also a powerful way for human beings to relate to one another and to express intimacy. " Porter and Holmes (cited above).
   
   1. What is sexuality?
      1. Sexuality is an energy force expressed in:
         
         • our speech
         • our movement
         • vitality
         • expression of self
           
           
      2. Sexuality is not just a biological function of intercourse and orgasm. It is expressed by:
         
   • our self perceptions of being attractive
   • our style of dressing 
   • how we interact and our conversations with peers
   • in our daydreams
     
   4. Sexuality is an identity. Whether one is active in intercourse, sexuality may be expressed by the way one dresses and interacts.
      
      • Human sexuality starts in early childhood (puberty or before) and continues through out the
         life cycle.
        
      • It takes different forms depending on the individual's physical condition, beliefs and norms, 
        their preferences (e.g.; homosexual or heterosexual) and their opportunities (single, married).
   
   Skim this article about sex and the elderly- CLICK HERE
   
   
   2.  Physical Changes In Women 
      
                   Women

   Masters and Johnson's study (read about Master's and Johnson in your text p.125)  found that women experience more changes in the  physiology (how they work) of sexual organs than men do.

   
   
   1. The period of climacteric (cli-mack-ter-ick) and menopause
      This time usually begins around the age 40 and is complete in most women by age 55. The time it takes for all of the productive changes to occur differs from woman to woman.
      
    
   1. This is the time in a woman's life that marks the cessation of her reproductive period. It is composed of three phases:
      
      • pre-menopausal
      • menopause
      • post-menopausal
        
        
      1. Pre-Menopausal - Usually begins around the age of 40.

         During this period, there is a drop in the estrogen levels, the primary female hormone.

         This drop is responsible for the physical and psychological symptoms many women experience such as hot flashes, chills, headaches and depression.

      2. Menopause - Actual menopause is defined as a time when monthly periods become irregular and eventually stop.

         Although some women stop menstruating around age 40, others may still be having regular periods in their mid-50's. Ovulation may continue for a year or two after the last period and women should continue to use contraceptives during this time. Pregnancy at this time is possible and people refer to these children as "menopause babies".

      3. Post-Menopausal - During this time, women experience gradual changes in the vagina.
         
         • Thinning of the vaginal wall occurs along with the vagina shortening and becoming dryer 
           (diminished lubrication may make intercourse painful).
           
         • There can be a number of psychological responses to menopause - 
           from loss of child bearing years to feelings of joy and a new freedom.
           
         • Because the ovaries stop producing estrogen, skin changes occur. There may be a 
           thinning of the skin and vertical creases around the mouth.
           
   2. Psychological Myths
      There are also a host of psychological myths regarding the sexuality in older women. Many can be the basis of a sexual dysfunction. For examples, cohorts of this generation were told:
      

      • good girls don't do it
      • it's for procreation only
      • I'm too old
      • a woman's sex drive is not as strong as a man's
      • it is unnatural to desire sex after menopause
        

   During this time, a woman may take longer to respond to sexual stimulation. The pre-orgasmic phase (the phase where sexual tension is building) is extended in duration. 
   
   This can be a time when a woman can take time to enjoy herself. The pressure to respond quickly is relieved and hugging and closeness can be enhanced.

   3. Some physicians believe that the symptoms such as hot flashes and headaches, that accompany the climacteric may be lessened by hormone replacement therapy (also know as HRT) in which women take a low dose of estrogen and progesterone. HRT is now recommended only for a short period of time as it may increase the likelihood of breast cancer.  

   Each woman must outweigh the risks based on her family history, lifestyle, and beliefs. Some women are not candidates for HRT because of other medical conditions or family history of certain types of cancers. The forms that estrogen is given include: birth control pills, patches, creams and suppositories.

   For a great discussion on menopause from the Mayo clinic visit this site. http://www.mayoclinic.com/health/menopause/DS00119

   3.  Physical Changes In Men

      Reproductive changes in men are less dramatic. Sperm production declines gradually, but testosterone does not stop completely as estrogen does in women. A man may father children way into old age. At age 80 he may still be ½ as fertile as he was at age 25.

      Most men need more time to get an erection and feel less of an urgency to ejaculate. They have better ejaculatory control. The penis may not be as firm and most men experience a longer resolution phase during which time an erection is impossible. This resolution phase can last from 12 to 24 hours or more. Most men become flaccid sooner after ejaculation. These changes might allow for more pleasuring time. The pressure to perform can be less if the man and woman are educated about these physiological changes.

      1. Special Concerns:

   Picture courtesy of http://www.healthsquare.com/pdrfg/pd/chapters/fg4ch07.htm

   The prostate gland is often the problem when urinary problems arise. These difficulties are often due to nothing more than prostate enlargement or infection; but cancer is a possibility. Take any urinary irregularity as a signal to visit your doctor or urologist (Health Square.com).

   1. The prostate gland is located beneath the bladder and surrounds the urethra.  It may become increased in size and stiffen as a man ages. This may make it more difficult to urinate. 
      
      The  gland's purpose is to create fluid in semen that helps sperm survive in the acidic environment of the vagina. Unless the prostate gland gets infected it is not a serious condition. If it becomes enlarged and blocks urination it is treated by a procedure called a TURP, or trans urethral repair of the prostate. Surgeons insert surgical repair instruments up through the penis .

   2. Cancer of the prostate becomes a serious threat during middle age and peaks between ages 60-80. Enlargement of the gland does not cause cancer (we do not know what the cause is); however, enlargement may be misdiagnosed as cancer until further diagnostic tests are done.

   3. Pathologies:

   Enlargement of the prostate gland for any reason can be misunderstood and stimulate a fear of impotence. There is a fear that  the risk of surgery for any reason might bring permanent dysfunction.

    

   Check out this handout- To Your Health, A Prostate Primer- What You Need To Know
   

   Penile implants
   
   Before Viagra, most erection problems were treated with penile implants. They are still used today for nerve damage or other erectile problems when Viagra is not indicated. 
   
   Most implants are inflatable prosthetic devices that have a reservoir, filled with silicone, that is implanted under the abdominal muscles. An inflatable cylinder in the penis can be inflated using a pump that is implanted inside the scrotum. 
   
   A man can compress the pump to fill the cylinders from the reservoir producing a 
   penile erection. A small release valve in the lower portion of the pump bulb releases fluid to return the penis to a flaccid state.
   
   There is a wealth of information about erectile dysfunction at this site. http://accuweather.healthology.com/focus_index.asp Choose View Entire Library to find the subject
   
    There is even a video broadcast on penile implants. 

   1. Other Permanent causes of impotency:
      
      • diabetes- affects the  vascular system responsible for penile erection 
      • arthritis- can create painful positioning during intercourse
      • alcohol - affects desire and sexual response
      • medications and illness may affect sexual expression (high blood pressure, sedatives, antidepressants, antihistamines, pain medications which affect blood pressure)
      • chronic illness effects self-esteem and self-worth and may cause men 
         to question their sexual adequacy
    
   
   
   III. Benefits of Aging and Sex

   Believe it or not, there are some definite advantages to growing older when it comes to sex. For example, because most become more comfortable with their bodies, the need to rush into intercourse is relaxed. Here are other advantages:

   •         Because erection and lubrication take longer, there is more time for      
             foreplay, kissing, touching, stroking, and a decrease  need to " perform". 
             One is not so anxious to have intercourse. 

    

   • Because children are usually raised, there are no kids around and you are less likely to be  interrupted. 

   • After menopause there is no concern about unwanted pregnancy.

   • There is more time to hold, to touch, and for closeness.

   • Expectations that create anxiety are lessened.

   • One can be more relaxed and less nervous.

   • Older adults are more likely to know their own bodies better and what pleases them.

   IV. Studies:

   Some early studies (1948) measured orgasm and found that there is a gradual decline in sexual interest with age. Problem is that sexual interest was defined as orgasm. As you have seen sexuality is more than  just orgasm. These early sexual studies looked at sexual function in adults. The major problem with these studies is that adults were defined as aged 16-20. In Master and Johnson's study, not many people over the age of 60 were studied.

   1. What might be other problems with studies that say there can be a gradual decline in sexual interest with age?
      
   • No sexual studies had previously been done (this was not a topic to talk about). 
     How can we separate out the cohort effect from the effects of aging? 
     What was this generation's norm around sexuality and 
     sexual expression? We have no studies to form a baseline of behavior. 
     
   • We do know that today's older adults generally are not comfortable talking about their sexuality.
     
   • Women were taught that sex was nasty.
     
   • The norm was to be embarrassed to admit to sexual activity because of cultural prohibitions.
     
   2. Studies that show that interest declines with age are not based on any physiological reasons. Why might women researched say they lose interest more than men do? Here are some of the reasons:
      
   • Cultural issues-societal permission for men to be sexually active and not women (good girls don't).
     
   • Because women live longer, many do not have partners. There are more women than men after age 
     65 (almost 1½ times more women), and old men generally look for younger women. 

   
   

   V. Adult Children and Long-Term Care Staff

   Another reason for the invisibility of the older adult's sexuality is the uncomfortable feelings of adult children and staff with parents and patients' sexual activity. Were you uncomfortable with the thought of your grandparents or parents being sexual active? 

   These attitudes make older people uncomfortable in telling family members about their activities or it reduces their behavior to sneaking and hiding. People often tease and ridicule older adults sexuality and facilities control relationships with other residents. 

   Scholars suggest useful guidelines in assessing residents' competencies regarding intimate relationships:

   • the resident must have the capacity to be aware of the relationship
   • they must be able to avoid exploitation
   • and the residents must have the awareness to assess their potential risk

   I have heard stories of adults in Florida who keep two apartments side by side so children are not aware that they are living together. Portable telephones make it possible for them to live in one apartment but answer the telephone in another. 
   
   

   Approaches to Sexuality: Taken from http://www.amda.com/caring/february2002/sex.htm
   
   Several approaches to sexuality in nursing homes have been reported:
   
   Religious & Ethical:
   Many nursing homes are operated by religious groups as ministries of service, and many nursing home staff, even in non-sectarian nursing homes, see their work as religiously motivated. They draw support from their beliefs for their sometimes thankless efforts. These staff may approach sexual issues from the standpoint of the moral teachings of their faith or from a general ethical perspective.
   
   Clinical:
   Some nursing homes, especially those with academic affiliations, approach sexuality from a clinical standpoint. They seek to understand biological, psychological, and sociological aspects of sexuality. They promote behavioral interventions, and recommend drug treatment when necessary for intractable, disruptive behaviors. The clinical approach to sexuality, including drug therapy, was recently reviewed by Hosam Kamel, MD, of St. Louis University's Division of Geriatric Medicine (Ann Long Term Care 2001;9:64-72).
   
   Advocacy:
   Some nursing homes and professionals frame sexuality as a matter of resident rights. They emphasize an approach that seeks to reduce the restrictive effects of institutions and staffs on sexual expression (Kelly WA. Nursing Home Medicine 1995, cited above).
   
   Staff Education:
   Most approaches identify a key role for staff knowledge and attitudes, and, thus, rely heavily on staff education. Dr. Kamel's review outlines strategies that can be used by facilities--and reinforced with staff education--to protect the sexual rights of residents. These strategies include such simple practices as always knocking before entering a resident's room. Studies have demonstrated the effectiveness of education on staff's ability to handle sexual behaviors (Steinke EE. Journal of Continuing Education in Nursing 1997;28:59-63).

   VI. Homosexuality

   The characteristics of gay and lesbian couples are much the same as those of heterosexual couples. Sexual expression is the one difference between heterosexual couples and gay or lesbian couples. Less is known about the course of gay and lesbian relationships than heterosexual relationships because they have been almost eliminated from research. When they are examined, it is usually in relationship to, or comparison to, married heterosexuals. Homosexual relationships in many ways, are the least accepted form of cohabitation. Until quite recently their behavior was severely condemned in our society. It was considered morally wrong and unhealthy. In fact, until the 1960's homosexuality was listed as a psychological disorder in the psychological journals.  Long-term care remains a problem for older gays and lesbians. Even though many have been "out" before they entered LTC facilities they must "go back in," so to speak. Homosexuality is still not accepted in most nursing homes.  Please read more about the psychological issues for older gays and lesbian couples at this web site.  http://www.webster.edu/~woolflm/oldergay.html and this one on financial issues for gay couples.  Study: Aging gay couples face fiscal burden And for a chuckle check out your handout on Heterosexual questionnaire.  VII. MARRIAGE-

   Want a chuckle: Check out How to Be A Good Wife at the electronic handouts for this week. It was taken from a 1950's high school economics book. 

   The vast majority of adults want their love relationships to result in marriage, although Americans are taking longer to get there. The median age of first marriage for adults in the U.S. has been rising for several decades. From 1960 to 1988 the median age for men rose about 3 years (from roughly age 23  to 26 years), and the age for women rose  nearly 4 years (age 20 years  to 24 years). More than 90% of American adults are likely to marry. 

   As anyone who has tried it knows, marriage is hard work. Most of us have an intuitive sense that certain factors, such as similarity of interests and values, age of the couple, and so forth, make a difference in the probability that a marriage will succeed. But we may not be aware of other important determinants.

   
   One of the clearest factors for marital success is a basis of similarity of values and interests - this extends across a wide variety of cultures and societies.
   
   A second important factor in enduring marriages is the relative maturity of the two partners at the time they are married. In part, the age issue relates to Erikson's belief that intimacy cannot be achieved until after one's identity is established.
   
   Another reason that marriages may or may not last is the degree of financial security present. Financial difficulties have a negative affect on marriages and increases the likelihood they will end in divorce. 

   
   
   
   VIII. DEVELOPMENTAL ISSUES IN MARRIAGE
   
   A. Change

   
   
   Roger Gould saw the central issue in marriage as how one tolerates growth and change. He described the ideal as when change was not only tolerated but welcomed as an interesting improvement in the relationship and the beginning of the next growth-step for the partner.
   
   The likelihood of such a marriage is not very great. Change is usually perceived as a threat. We are more comfortable with things just the way they are.
   Alvin Toffler argues that it is utterly unlikely that marriage as a long-term commitment can last.
   
   He sees instead, serial marriage with a pattern of marriage-divorce- remarriage-divorce-remarriage, best suited for what he sees as an era that does not value permanence in anything.
   
   Lillian Troll offers some possibilities that partners in a marriage can remain compatible over the course of years. He describes the outcomes that are likely on the basis of the personality growth and development of the partners.

    

   • If neither partner becomes more complex, the match can remain 
     good.
     
     
   • The match can also remain compatible if both partners become less 
     complex (as sometimes occurs in late life)
     
   • It can remain compatible if both partners become more complex and 
     move in compatible directions. This is a popular idea among young 
     adults. It is also the one that seems to be most difficult to sustain.
     
   • If one partner grows toward greater complexity and the other does 
     not, or if one becomes less complex and the other remains stable, it is 
     easy to see how the possibilities for uneven growth and mismatching can 
     be acute.

   
   
   XI. MARITAL SATISFACTION
   

   1. Overall marital satisfaction is highest at the beginning of the marriage, falls until the children begin leaving home, and rises again in later life. This "U" shaped pattern depicts satisfaction at the top of both sides of the "U" shape

   

                                                                               Level of Marital Satisfaction
   

   1. In its early days marriage is at its most intense. During this honeymoon phase the couple spend considerable time together, usually resulting in high satisfaction.
      
   2. As the bliss of the honeymoon phase becomes a monotony, marital satisfaction tends to decline, especially for women. This decline in satisfaction holds for couples of diverse educational, religious, 
      employment, age, and racial backgrounds.
      

   1. The most common reason given for this drop is the birth of 
      children. For most couples having children means having 
      substantially less time to devote to the marriage.
      
   2. The fact that even childless couples experience a modest decline 
      in marital satisfaction means that the drop is not totally due to 
      having children.

   3. By mid-life marital satisfaction hits rock bottom, and some differences between husbands and wives emerge.
      

   1. Husbands at all stages of the marriage tend to describe it in 
      positive terms, whereas middle-aged wives tend to be more critical.
      
   2. A 1975 study (Lowenthal, Thurnher, & Chiriboga) found that 80% of 
      husbands, but only 40% of wives rated their marriages favorably in 
      mid-life.
      
   3. Wives' chief complaint about their husbands was that they were too 
      dependent and "clingy"; interestingly, this difference in feelings is 
      sometimes noted in newlyweds, but it is the husbands who describe their 
      wives in such terms.

   4. Marital satisfaction usually begins to rebound, at least temporarily, following the launching of adult children. The improvement is especially noteworthy in women, and it stems partly from the increased financial security after children leave, the relief from the day-to-day duties of parenting, and the additional time that wives have with their husbands.
      
   5.  For some middle-aged couples, however, marital satisfaction continues to be low. These couples tend to be ones who have grown apart but who continue to live together. In essence, they have become 
      "emotionally divorced". For these couples more time together is not a welcome change.

    

   2. Overall, marital satisfaction ebbs and flows over time. The pattern of a particular marriage over the years is determined by the nature of the dependency of each spouse on the other.
      
   1. When dependence is mutual and about equal the marriage is strong 
      and close.
      
   2. When the dependence of one partner is much higher than that of the 
      other however, the marriage is likely to be characterized by stress and 
      conflict.
      
   3. Changes in individual lives over adulthood shift the balance of 
      dependence from one partner to the other; for example, one partner may 
      go back to school, become ill, or lose status. Learning how to deal 
      with these changes is the secret to long and happy marriages.

   
   
   X. LONG-TERM MARRIAGES
   
   A. Researchers know very little about long-term marriages especially from a developmental perspective.
   

   1. One of the only longitudinal studies of long-term marriages was conducted by Weishaus and Field (1988) who followed 17 couples in the Berkeley Studies. These couples had been married between 50 and 69 years and had been interviewed from time to time since their children were born in 1928 and 1929. The 1982-1984 interview revealed the following:

   They found these couples fit into four categories:
   

   1. stable-positive marriages, which had maintained moderately high 
      to high levels of satisfaction throughout heir duration.
      
   2. stable-neutral marriages, in which couples had never experienced 
      high emotionality or intimacy.
      
   3. stable-negative marriages, in which couples had experienced 
      primarily negative emotions throughout.
      
   4. curvilinear marriages, which had showed the typical drop in 
      satisfaction in mid-life but which had risen in later life.

   
   
   Twelve of the 17 marriages showed either the curvilinear or stable-positive patterns.
   
   All of the couples demonstrated shared and separate interests, and all showed commitment to the marriage, and acceptance of each other.
   
   Couples with curvilinear or stable-positive marriages also demonstrated understanding, affection, love, and were uncritical of their mates and their marriages.

   These findings point out the importance of a willingness to work at the marital relationship to keep it going. The continued sense of commitment to the relationship and to one's spouse is also key.

   
   
   
   XI. Divorce and Re-Parenting
   

   1. Many unions do not survive, ending in desertion, separation, annulment, or divorce. Every social system has some way of ending a relationship; the forms and consequences reflect the values and options of the time and place.
      
   2. Just as marriage involves a change in social role and status from "single" to "married", so does the process of divorce .
      

   1. This transition involves not only shifting back to a single life again, 
      but also reformulating a range of social ties--the ex-spouse, 
      children, relatives, and  friends.

   
   The END