Stephen Holzapfel, MD, CCFP, FCFP, Medical Director, Sexual Medicine Counselling Unit,
Sunnybrook and Women's College Health Sciences Centre;
Associate Professor, Department of Family and Community Medicine,
University of Toronto, Toronto, ON.

Sexual function and self-perception is integral to our sense of self and well-being. Yet we live in a society that desexualizes older people, especially women. Aging women experience changes in their sexuality that are often associated with negative effects on mood. Can we help women who are distressed by these changes?

Mood and Sexuality Changes Associated with Menopause
Most women make the transition through menopause with few long-term negative effects on their sexuality. Two-thirds of women in relationships are still sexually active in their 60s, with a gradual decline to about 25% of couples in their 80s. While many are comfortable with these changes, some are distressed by the loss of physical intimacy. The absence of a partner due to death, divorce or partner illness curtails women's sexual lives more often than do their own medical issues. Aging men face increasing erectile dysfunction, with one in seven men experiencing complete impotence by age 70.¹ Given that North American women marry men who are on average four years older than themselves, and that men die six years sooner, most women face up to a decade of widowhood.

Laumann et al.

One of the most moving speeches I have ever heard was given several years ago at the annual meeting of the American Geriatrics Society. Dr. Masters, a distinguished researcher in the field of human sexuality, was being honoured for his many contributions. Masters pioneered the concept that the human need for intimacy did not disappear at some arbitrary age, but rather was a lifetime need. He expressed very clearly the only two requirements for continuing sexuality in old age: a reasonable state of general health, and availability of a suitable partner. He also stressed that sexuality was not limited to sexual intercourse, and that the presence of erectile dysfunction (then still called impotence) did not necessarily mean the end of all sexual intimacy.

Fortunately, there is now a much better appreciation of the fact that older persons can remain sexually active. It makes as much sense to assume that after a certain age people no longer need to eat! One of the interesting by-products of the research started by Dr. Masters is our understanding of the many medical conditions that can contribute to sexual dysfunction, particularly erectile dysfunction. When I was in medical school, we were taught that, in the absence of severe neurological impairment (e.g., paraplegia), most causes of erectile dysfunction (ED) were psychological in origin. We now understand that medical disorders are the root cause of many cases of ED. In his excellent review of ED, Dr. Peter Pommerville provides the knowledge and tools a primary care physician requires for evaluating an older man with this condition. As well, Dr. Roland Tremblay discusses the emerging concept of andropause, its diagnosis and possible therapeutic strategies.

Of course, men are only half of the sexual intimacy story. Women also have a need for sexual intimacy, and the two principles that Dr. Masters championed (reasonable general health, availability of a suitable partner) apply to both men and women. However, the issues do differ between the sexes, and we have a trio of articles that pertain specifically to women. Dr. Stephen Holzapfel discusses the physical and mental aspects of maintaining sexual health in older women. Dr. Scott Farrell discusses the broad topic of urogenital health in elderly women, while Dr. Shawna Johnston focuses on the recognition and management of a common problem in older women, atrophic vaginitis.

Regular readers of this journal already know that geriatric medicine differs from practice in younger adults for a variety of reasons (atypical presentation, iatrogenesis, presentation with geriatric syndromes, multiple comorbidity, etc.). One major difference when performing a physical examination of an older person is that the neurological examination is usually required to understand the patient's problems, even when the presentation is not primarily neurological. Dr. David Gladstone and Dr. Sandra Black discuss the approach to the neurological exam in normal aging and in diseases common in the elderly. In a complementary article, Dr. Daniel Silverman discusses neuronuclear imaging in the evaluation of early dementia.

As usual, we have a potpourri of other articles, including Dr. Arthur Bookman's discussion of new advances in the treatment of rheumatoid arthritis, and Dr. Ali Ahmed's review of digoxin in older adults with heart failure.

Enjoy this issue.

Margaret C Gibson, PhD, CPsych
Psychologist
Veterans Care Program
Parkwood Hospital Site
St. Joseph's Health Centre
London, Ontario

Sexual health is defined by the World Health Organization as the integration of the physical, emotional, intellectual and social aspects of sexual being in ways that are positively enriching and that enhance personality, communication and love.¹ Sexual health includes elements that are sensory, cognitive, emotional, physical, spiritual, functional, relational, social, cultural and historical. It reflects our basic concepts of ourselves as male, female, man, woman, child, mother, father, partner, lover and friend. Sexual health includes overt sexual behaviours, but is about much more than behaviours alone. It is about who we are, about our connections to others with whom we share both basic evolutionary drives and the capacity for profound interpersonal bonds. Sexual health involves having a sense of comfort with the life course of one's own sexuality. It is an integral part of overall psychological well-being and quality of life.