Sex Therapy > Aging and Sexual Desire in Men: Applying Mindfulness


Aging and Sexual Desire in Men: Applying Mindfulness

By Dan Pollets
A middle-age couple present for sex therapy complaining  that they are  no longer sexually active.  He states that he no sexual drive.  He says he is under stress at work and feels depressed.   His wife is concerned that she is no longer attractive to him.

55 year old married executive states that his sex drive is strong but it is difficult to maintain his erection.  His says that his wife lack interest in sex.  He has begun to entertain thoughts of an affair.

A 49 year old divorced man with diabetes is fearful of dating.  In his last sexual encounter, he was unable to achieve and maintain an erection.  He now fears failing and humiliating himself if he were to be sexual.
These clinical vignettes are examples of cases that I treat in my role as a sex and couples psychotherapist. They clearly speak to the issue of aging and sexuality.  This topic of sexuality in the aging man presents a proverbial “good news/bad news” scenario. We boomers are living and thriving well into our 80’s and 90’s, as our life expectancy has grown generation to generation (good news). Bad news: In terms of our sexuality, around the half century mark, in the words of Paul Simon, our “tools of love wear down.” No man escapes what the Buddhists would call “impermanence”.  In healthy men, around the fifth and sixth decade of life, symptoms or aging or dysfunction begins to happen (in both men and women mind you) which alters, changes, diminishes, and sometimes attenuates sexual function. When you study and treat sexual dysfunction, it soon becomes abundantly clear that many factors impact on sexuality and that you cannot isolate the purely physical/medical issues from the emotional. Sex also takes place between two people so the quality of the relationship is also of immense importance when trying to understand sexual dysfunction.  Now throw in attitudes, religion, and cultural influences and it really gets convoluted.  We are one complicated species and the physical (body) is always bumping up against and affecting the mind and vice versa. Sexual desire is a product of an interaction between biology (hormonal), thoughts that generate the wish to behavior sexually, and emotions that drive our motivation that result in a willingness to behave sexually. This psychological dimension is very much influenced by attitudes about sex (e.g. “older people are neither attractive nor sexual”) and the quality and satisfaction of the relationship...

In this brief chapter, I will describe the issues relevant to the topic of aging and sexual desire in order to provide the reader with some helpful information so there can emerge a “map” for the journey ahead. My hope is to provide clarity; here’s what you have to look forward to and expect.  Forearmed is forewarned, right?  

In the adaptation to the ever changing conditions that characterize the aging process, there is an attitude of the mind derived from Buddhist Psychology called Mindfulness that serves to expedite the coping and adaptation process.  When Mindful, we can be present and non-reactive to whatever difficulty falls in our path.  Mindfulness helps us step back from negative judgment and helps us to be more accepting of the moment whatever it brings.  On the other hand, if one tries to “hold on,” denying the inevitable, more resistance is generated which ultimately results in more pain and suffering.  Applying this to the topic at hand, if you are aware of the predicted changes to be encountered regarding sexual function and desire in the aging process, and if mindful,  you can choose to be more accepting. You can practice letting go of what cannot be avoided or changed (the aging process) and continue to remain sexual despite the age-related diminishment of function.  Sexuality can thus be perpetuated into the ninth inning so to speak.

Age and Desire:


While we have doubled our life expectancy over the past century, our sexual equipment begins to lose functioning around the 5th decade in healthy men.  However, this is highly variable; many factors will determine the quality of sexual function and desire.   A recent large sample survey conducted by DeLamater & Sill (2005) found that in both men and women, sexual desire decreased with age but not nearly as fast as popular belief.  These authors found that it is not until age 75 or older that the majority of men report a low level of sexual desire.  Low desire jumps from 27% of the sample at age 65 to 69 to 50% at age 70 to 77. Another study found that 63% of men age 80 to 102 continued to be sexually active (Meston, 1977).  Good news: there are many older persons having a good time being sexual.  The trick is to adopt a healthy life-style, adapt to the normative changes in the sexual equipment, keep on working on your intimate relationship, and cultivate a “Zen” attitude of acceptance (Mindfulness).

Factors Relevant to Sexual Desire in Mid-Life:


Testosterone:
The age-related decrease in libido noted among men is most frequently attributed to a decline in testosterone levels and to changes in receptor site sensitivity to androgen.  Around the 5th decade of life, testosterone production gradually declines.  By age 80, it may be only a sixth of a younger man.  The caveat is that while lowered testosterone parallels the decline in sexual libido noted with age, there is little evidence to suggest that loading up on testosterone replacement will augment sexual drive with men with normal baseline testosterone.  However, if you are suffering from what is called “hypoactive desire disorder (HSDD), and one in five men post age 50 do, you might benefit from testosterone replacement.  If you have absolutely no libido, are depressed, have poor concentration and energy you would be wise to consult your urologist and have your hormonal blood levels checked.

Erectile Function:
Normal age-related change in erectile function will affect sexual desire. These symptoms include a decrease in blood flow to the scrotum and penis; reduced tensing of the scrotal sac and delayed erection.  Where a younger man may achieve a full erection in seconds, an older man may require several minutes to attain a similar response. More time and more direct penile stimulation may be necessary to achieve the desired results. Having a cooperative partner who is happy to provide manual and/or oral pleasuring will help facilitate and augment arousal. Assuming a mental attitude of nonjudgment, focusing your attention on the pleasurable sensations will help create the comfortable and relaxed atmosphere that promotes sexual arousal and intimacy. Being self-critical and demanding of a “performance” or comparing yourself to the way you responded when younger will create anxiety and stress. The stress response reduces reduce blood flow and hence, erectile function.

More bad news:
Penile sensitivity also decreases with age.  Bottom line: to compensate you need to have more time for sexual play and a tranquil, comfortable sexual “climate” in order to maximize blood flow and sensitivity.  Being able to receive direct manual or oral stimulation prior to intromission and possibly at periods throughout the sex act will help to sustain erection until orgasm.  “Adapt or perish” as they say.  If you try to hold onto the way it was and resists the inevitable; that is, physical change accompanying aging, you will no doubt experience more pressure and anxiety. The male phallus does not like pressure and will be likely to fold in its presence.  While penile rigidity declines gradually beginning in most men at age 60, couples can compensate by experimenting with more creative and novel foreplay and stimulation as well as different coital positions.

Illness and Medication:
Medical illness, especially those that impact on vascular health, can affect erectile functioning and desire.  This is as good an argument as any for men to adopt a healthy lifestyle.   Good nutrition, exercise, stress management, and seeing a doctor regularly are all positively associated with keeping blood vessels healthy and the sexual equipment running smoothly.  High blood pressure, hypertension, obesity and diabetes are strongly associated with erectile dysfunction (ED).  For example, within five years after the onset of type II diabetes, 60% of the male patients have some form of sexual dysfunction (LeVine, 1992).  Diabetes affects both the quality of the blood vessel causing arterial insufficiency.  The neurological changes (neuropathy) associated with diabetes also contributes to ED in older diabetic men.  The “good news” is that obesity, hypertension and type II diabetes are related to a number of life style behaviors that can be altered.  There is the possibility to control negative health outcome and avoid disease.  If you have a poor diet, rich in animal fat and processed food, live a sedentary existence as a couch potato, have depression and/or chronic stress in your life you are at risk for premature aging in the sexuality department.

There are a wide variety of drugs that have been reported to impair erectile ability and reduce desire. I will mention the major culprits. I suggest checking with your physician if you have concerns.  As we age, our metabolism changes (slows) which affects physiologic drug distribution which renders older persons more vulnerable to the side effects of drugs. Among medications, antihypertensive agents and diuretics are primary offenders causing impaired erections.  Cardiovascular drugs, cancer chemotherapy agents, anti-anxiety meds, anti-psychotics, and a wide variety of antidepressants, bipolar meds, and numerous drugs of abuse (cocaine, alcohol, narcotics, and amphetamines) have all been linked to impaired erectile function.  With diseases such as depression, hypertension and vascular diseases it is difficult to determine the extent to which the sexual dysfunction is the result of the disease or the treatment (medication) as they both impact the sexual response.

It is important to understand that these physical changes and effects are happening to an aging man with a history and emotions.  The interaction between mind and body has strong implications for sexual desire.  It is a generalization but true that most men attach self-esteem and worth to their sexual response and performance.  Men are conditioned to garner self-esteem via competition, achievement and by succeeding.  This has been described as the “boy code” by psychologists.  In my practice, I have found men with relatively minor sexual dysfunction to be “high reactors” in that they feel terrible and ashamed about their reduced functioning. They experience it as a diminished view of self. These are men who are likely to withdraw into forms of distraction and self-medication and avoid sexual intimacy.  Unable to perform in a way that meets some standard, avoiding intimacy has the effect of protecting them from being threatened and humiliated. These men suffer and the relationship suffers. On the other hand, there are men who have vascular disease, on medications, and strive to accept the loss and do the best they can with what they have. They focus on pleasure and intimacy and stay sexual.  It is our response, what we feel, experience, and attribute to the physical changes that determine to a significant degree if we remain sexual.  We are emotional creatures (yes, even men), and how we end up feeling about our sexual response determines our sexual and relationship behavior.  If it is all about performance and being a stud, sexual changes associated with normative aging will be fraught with anxiety and loss.  Withdrawing from the relationship or other problematic relationship behaviors would then make sense but be self-defeating at the very least.

Relationship Factors: 


As a sex therapist that treats couples, I cannot overestimate the importance of a secure, trusting, communicative, and empathic relationship to sexuality as we age (at any age).  Anecdotal case material from my 35 years in psychotherapy practice as well as the research speaks to sexual desire as an interactive and relational phenomenon and not exclusively a biologic or physical entity.  If you are in good physical health and are accepting of normative age-related sexual changes and you have a partner you feel attracted to and secure with, you can be sexually active into your 80s.  Bad news: marital conflict, relationship imbalances, commitment issues, intimacy and communication problems, lack of trust, mismatches in sexual desire, boredom and poor sexual technique are some of the common sources of sexual dissatisfaction guaranteed to reduce the desire to engage sexually.  These issues take the zest out of sex and likely lead to the deadening of interest and ultimately avoidance.  Long suffering resentments and anger built up over the years as well as feelings of entrapment is the “wet blanket” for sexual desire.  The bottom line is that relational satisfaction is closely linked to sexual satisfaction in older couples. 

Sex therapy might be the antidote if tension and conflict characterize your relationship and the sex has become rote, uninspired, and absent.  There is help available if you can acknowledge the need and seek out an experienced sex therapist.  Study after study regarding sex and aging has noted the strong mediating influence that a “securely attached” relationship has on maintaining the satisfactory sexual relationship as one age.  An intimate and securely attached relationship inoculates you from having to abandon sex just because your body and its sexual apparatus have become less functional.  In such a quality relationship you are in sync with your partner and can communicate how you need to be pleased (and vice versa).  It feels safe to express sexual needs and to ask for different forms of stimulation.  It’s like being able to dance the tango smoothly in step.  If you are emotionally intimate, secure in your love and attraction to one another, you are propelled to seek each other out sexually and the sex, in turn, pleasurably reinforces your connection.  In this dance, mind, body, and relationship are inextricably linked. 

Mindfulness: Secret Elixir of Sexual Health:


Mindfulness is the lynchpin of Buddhist Psychology and is practiced as a means of training attention and improving awareness.  The objective is to reduce suffering.  Suffering in this psychology is conceptualized as resulting from our inability to accept change or impermanence and to remain attached (to whatever does not serve us including self-defeating thoughts and emotions).  When we are mindful we are in a mental state of “non-reactive, non-judgmental awareness.”  We practice (meditation) to be with things as they are and not as we wish them to be, the way they were, or even as we think they might be in the future.  When mindful, we are present in the moment, leaning in to what is happening embracing whatever presents itself with equanimity and gratitude.  Now we cannot all be Buddha like or enlightened but this is a mindset that will be in the service of healthy adaptation to our inevitably aging bodies.  Instead of fearing the changing conditions and symptoms of aging, trying desperately to hold on and resist, mindfulness leads to acceptance and then to doing the best you can with what you have, no matter how old or disabled. 

You don’t have to like it, but resisting the change or comparing yourself with what you had or did when you were younger is not helpful.   Keeping yourself in a state where you desire sex when everything moves slower, feels different, and sags requires more than a pill or fitter muscles, it necessitates a “mindful brain” that is equal parts self-accepting and compassionate and relational: connected and connecting.  The embers of the sexual fire then do not extinguish but are fanned to a mellow glow by loving presence.

Dr. Dan Pollets is an ASSECT credentialed sex therapist and well trained in cutting edge couples, individual and group therapies. 

Dr. Pollets is in private practice in Medford, Massachusetts and treats patients from Boston, Cambridge, Arlington, Winchester, Somerville, Melrose and the greater Boston Metro MA area.  He is Associate Clinical Professor at Boston University School of Medicine and a published author in the Psychology Today web site.