Sex, Race, and Aging: why fifty is not the new thirty in bed

(And it’s a good thing!)

Photo credit: Elana Emar via The EyeOpener

I consider it a privilege to talk to my patients about sex. I won’t spill any details about particular patients here, but I’m often surprised that my patients can be so forthcoming about their sex lives. Is there any other setting where you meet someone and within five minutes hear details about her relationship, intimacy, or sexual activity?

As a urogynecologist, most of my patients are women that are mid-life and older. The common issues I see in my clinic are bladder leak (urinary incontinence) and vaginal bulge (pelvic organ prolapse), which are issues that tend to affect women later in life. However, sex is the most common topic that comes up with my patients, regardless of why they originally came in.

I do want to bring up a theme that I’ve observed and is supported in research: women have sex across the age spectrum. I have patients that are seventy years old still having intercourse. I also have patients in their fifties who bluntly tell me they explore other types of intimacy with their partner, and penetrative intercourse is no longer a priority for them. I’m often reminded that normal sexuality and aging is under-appreciated in medicine. We spend so much time focusing on what’s wrong with people, that we may forget that not all change is bad. Some changes are normal, or physiologic, like the way sexuality changes for women in mid-life and menopause.

So what is normal? A woman’s body is constantly undergoing changes in sex hormones, from birth through older adulthood. Mid-life and the menopausal transition involve major changes in sex hormones. These changes then gradually persist for the remainder of women’s lives. Hormones are only one aspect affecting sexuality — our social groups, family lives, culture, and experiences also play into the way we enjoy sex as we age. These aspects are in constant flux as well. Keeping all of these changes in mind, we know that although the frequency of sexual experiences may decrease as women age, the quality of the experience becomes more important. For a lot of women, intimacy and foreplay become the focus of their sexual experience as they get older.

I could talk about sex all day, and sometimes it seems that I do in clinic. But this is Pelvic Health for Brown Girls, after all. So for the purposes of this blog I want to highlight how pelvic floor disorders and race can relate to sexuality and aging. Changes in vaginal dryness with age deserves its own story, so I’ll discuss that on another day.

Pelvic Floor Disorders Affect Body Image, which Affects Sex

We know that body image and the way women perceive themselves are related to women’s perceptions of their sexual health. It’s no wonder, then, that women who experience problems with their pelvic floor also tie these issues to their sexual health. In one review, they found that problems with sexual health affect 30–50% of women, as opposed to 50–80% of women with pelvic floor disorders.

My prolapse patients express difficulties with sexuality in several ways. They are often worried that sex will damage their prolapse further (it won’t). They also are self-conscious of how their vaginal bulge appears. Interestingly, many of my heterosexual patients state that having a vaginal bulge does not seem to affect their partners’ interest in having sex with them.

For the majority of women, receiving treatment for their pelvic floor disorder improves their sexual health, including among women with incontinence or prolapse. The challenge is that many women may be too embarrassed to discuss these issues with their doctors. By the time patients make it to my specialty clinic, they are often surprised that there are doctors who can treat these issues.

There are Differences in Race and Sexual Activity for Mid-Life Women

During interviews of over 3,000 U.S. women ages 40–55, the Study of Women’s Health Across the Nation (SWAN) helped us learn a lot about women’s sexual behaviors. There’s a few trends to note from their study regarding ethnicity and sex (mostly found in the study’s “Table 2”):

1. Over one-half (58.4%) of Japanese women did not have sex in the six months prior, as well as slightly less than half of Chinese women (43.9%). Otherwise, most women had sex either once a week or more.
2. Most women across ethnic groups expressed moderate or greater emotional satisfaction with their sex lives.
3. Hispanic, Chinese, and Japanese women were less likely to endorse extreme physical pleasure during sex, and more likely to endorse moderate physical pleasure compared to White and African-American women.
4. The majority of all women expressed interest in being sexually active with their partners in the past six months.
5. About 1 in 5 (or 20%) of all the women expressed having pain sometimes during intercourse.

I thought this study was especially interesting because, even though different ethnicities expressed differences in sexual pleasure and frequency, the majority still had sexual desire and were satisfied with their sex lives. I think this rings true in my clinic patients — some women have sex less frequently but are ok with that, but overall the majority of women still are interested in or are having sex, even around menopause.

Being in Los Angeles I see a large population of women of Latinx descent, particularly of Mexican descent and some from other parts of Central America. I think the SWAN study findings for Hispanic women are reflected in my patient population. These women often express being less sexually active but perceive that as normal as they age, often because of deeply-rooted religious and cultural beliefs. My Latinx patients commonly tell me they even stop having sex, or that it’s no longer important to them, in their late 40s, 50s, and 60s, which I don’t hear as commonly from my other patients.

I also think the findings about sexual behaviors and women of Asian descent are interesting in the SWAN study. I first learned about the phenom of “sexless marriages” in Japan through Episode 1 of Christiane Amanpour’s “Sex and Love around the World.” Other reports of infrequent sex exist about Chinese and Japanese women. These studies have focused on younger, married people, so it doesn’t entirely apply to the SWAN study population However, I think it’s fascinating that this study found a similar pattern of infrequent sex among women of Japanese and Chinese descent in the U.S.

Women DO Enjoy Sex in Mid-Life and Beyond

For those of us women still in our reproductive years, I think we have something to look forward to when it comes to our sex lives. The studies seem to show that women have more intimate, quality sex as we age, as opposed to having sex more frequently when younger. It’s important to know that most U.S. women can and do enjoy their sex lives during menopause. On the other hand, there’s a common belief that sex should be less enjoyable as women age because of the changes that happen around menopause. That’s just not true. There are treatments for the common issues affecting women’s sex lives as they age. Don’t be afraid to ask your doctor, and if you don’t like their answer ask for a referral to a specialist in women’s sexual health.