Introduction

A person's need for intimacy and closeness to another does not end at any age. Sexual function is an important quality-of-life issue for all women and is influenced by many factors, including culture, ethnicity, emotional state, age, previous sexual experiences, medical disorders, and drug use. (see Tables 114-1 and Table 114-2) Changes in sexual response associated with normal aging (see Table 116-1), medical disorders, incapacitation or death of a partner, or environment (eg, lack of privacy) are problems but not dysfunction per se. The cause of sexual dysfunction is usually multifactorial. Less is known about sexual function in elderly women than in elderly men; the interplay of emotional state, relationship issues, and physiology in women is complex and has not been completely elucidated. Dysfunction can be defined as the persistent impediment to a person's normal pattern of sexual interest, response, or both.

The Sexual History

Sexual function, one of the most important quality-of-life factors, should be assessed as part of the comprehensive care of a patient. It should be evaluated within the context of sexual orientation, psychologic and medical disorders, social situation, drug use (including over-the-counter drugs), environmental issues, partner issues, frequency, and satisfaction. Women define normal sexual activity for themselves based on past experiences, self-esteem, presence or absence of medical disorders, and partner issues. Health care practitioners must be careful not to interject their opinion on what constitutes acceptable sexual practice. For example, the continued sexual interest and activity of an 80- or 90-year-old woman, viewed as perfectly normal by her, might be misunderstood by her health care practitioners or others. Because sexual function is often measured only by frequency of intercourse, persons who live alone, have an incapacitated partner, have health problems, are lesbian, or practice masturbation may be erroneously regarded as sexually inactive. In addition, touching, fondling, kissing, holding, and other important components of sexual activity are rarely considered by health care practitioners.

The sexual history can be incorporated into the medical history.

Although many physicians lack training in sexual health, they should not avoid this subject because this area of health assessment is becoming more important for all women, not just older women. The sexual history should address the woman's interest in sex, frequency of spontaneous sexual thoughts and fantasies, frequency of masturbation, self-esteem, attraction to self and others, and past or present relationship issues. The patient's responses help determine whether the problem is situational. Questions should be nonjudgmental; asking "Do you have any problem with your ability to have sex?" or "Are you satisfied with your sex life?" indicates to the patient that the physician is willing to discuss this subject, even if no problem exists. A woman who acknowledges a problem should be further asked about how the problem began and how it affects her sexual activity and response and those of her partner. In both men and women, depression can cause sexual dysfunction, which can in turn cause depression. Thus, an assessment as to whether depression is a component should also be undertaken. Interviewing the partner may provide additional perspective on the nature of the problem.

The sexual history provides an opportunity to reinforce issues related to general health as well as to sexually transmitted diseases. An elderly person who has lost a spouse or long-term partner may not have had to deal with these issues previously and should be reminded about safe sex practices.