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Division of General Internal Medicine, Department of Medicine, University of California, San Diego School of Medicine, La JollaVeterans Affairs San Diego Healthcare System, Calif
Requests for reprints should be addressed to Elizabeth Barrett-Connor, MD, Distinguished Professor and Chief, Division of Epidemiology, Department of Family and Preventive Medicine, University of California, San Diego School of Medicine, 9500 Gilman Drive, Mail Code 0607, La Jolla, CA 92093-0607
Female sexual dysfunction is a focus of medical research, but few studies describe the prevalence and covariates of recent sexual activity and satisfaction in older community-dwelling women.
Methods
A total of 1303 older women from the Rancho Bernardo Study were mailed a questionnaire on general health, recent sexual activity, sexual satisfaction, and the Female Sexual Function Index.
Results
A total of 806 of 921 respondents (87.5%) aged 40 years or more answered questions about recent sexual activity. Their median age was 67 years; mean years since menopause was 25; most were upper-middle class; 57% had attended at least 1 year of college; and 90% reported good to excellent health. Half (49.8%) reported sexual activity within the past month with or without a partner, the majority of whom reported arousal (64.5%), lubrication (69%), and orgasm (67.1%) at least most of the time, although one third reported low, very low, or no sexual desire. Although frequency of arousal, lubrication, and orgasm decreased with age, the youngest (<55 years) and oldest (>80 years) women reported a higher frequency of orgasm satisfaction. Emotional closeness during sex was associated with more frequent arousal, lubrication, and orgasm; estrogen therapy was not. Overall, two thirds of sexually active women were moderately or very satisfied with their sex life, as were almost half of sexually inactive women.
Conclusion
Half these women were sexually active, with arousal, lubrication, and orgasm maintained into old age, despite low libido in one third. Sexual satisfaction increased with age and did not require sexual activity.
Although sexuality, particularly sexual dysfunction, is now a major focus of medical research, there are few studies of sexual activity and sexual satisfaction in community-dwelling older women.
studies have asked about satisfaction, desire, arousal, and orgasm in older women. The largest survey of female sexual activity leading to personal distress was mailed to a representative sample of 50,003 US women aged 18 to 101 years in 2006; 63% responded.
In that study, low desire (libido) was the most common problem reported by all age groups; women aged 45 to 64 years reported more sexually related distress than younger and older women.
We report a study of sexual activity and satisfaction as reported by older community-dwelling women from the Rancho Bernardo Study (RBS) cohort. We describe the prevalence of current sexual activity; characteristics associated with sexual activity, including demographics, self-reported health, menopause history, and hormone use; frequency of arousal, lubrication, orgasm, and pain during intercourse among sexually active women; and sexual desire and sexual satisfaction in sexually active and sexually inactive older women.
Materials and Methods
Study Population
The RBS included 82% of community-dwelling adult residents of Rancho Bernardo, a suburb of San Diego, California. Since inception in 1972-1974, Study participants have been followed annually by mail for vital status and morbidity, and every other year for specific conditions or behaviors potentially related to healthy aging. The Study was approved by the institutional review board of the University of California, San Diego. Mailed questionnaires reminded participants that responses were voluntary, and they did not need to answer any questions that they preferred not to answer.
Measures
In October 2002, 1303 surviving RBS community-dwelling women were mailed a questionnaire about physical and emotional health, menopause, hysterectomy status, current estrogen use, the presence or absence of an intimate partner, and the presence or absence of recent (past month) sexual activity with or without a partner. Standard 5-point scales with the responses “excellent,” “very good,” “good,” and “fair or poor” were used to assess self-rated physical and emotional health. The Female Sexual Function Index (FSFI)
The FSFI has demonstrated reliability and validity in women with or without sexual dysfunction, has good test-retest reliability for each of its individual domains (r = 0.79-0.86) and overall (Cronbach's alpha ≥ 0.82). The FSFI estimates the extent of difficulty in 6 domains of sexual function: desire, arousal, lubrication, orgasm, pain, and satisfaction.
We inserted one additional question: “Over the past 4 weeks, have you engaged in any sexual activity or intercourse?” for a total of 20 questions (Appendix 1, online, question 3). The first 2 questions were answered independently of partner status or recent sexual activity and relate to sexual desire. The next 11 questions were answered only by women who had engaged in sexual activity in the past 4 weeks, with or without a partner, and relate to arousal, lubrication, and orgasm. The next 4 questions concerned emotional closeness with a partner and pain associated with vaginal penetration. The 19th question addressed satisfaction with overall sexual life in all respondents who had a partner whether or not they were currently sexually active. The last question addressed overall sexual satisfaction with or without a partner.
The FSFI questionnaire specifies that sexual activity could include caressing, foreplay, masturbation, and intercourse. Intercourse was defined as penile penetration (entry) of the vagina. The questionnaire specifically stated, “You do not need to have a partner to answer this questionnaire.”
Statistical Analysis
Data from 806 of the 921 women (87.5%) aged 40 years or more who returned the questionnaire and answered the question about recent sexual activity with or without a partner in the past 4 weeks are the basis of this report. Baseline characteristics are summarized for the entire study cohort and compared between women who were sexually active and those who were not. Results are presented as means and standard deviations of continuous variables with t test used to evaluate significant differences. Categorical variables are shown as percentages, and associations are tested with chi-square tests. Age is analyzed by quartile based on the 806 respondents, with 201 or 202 women in each quartile: quartiles are age less than 55.13 years, 55.14 to 68.02 years, 68.03 to 79.91 years, and 79.92 years or more. Data are analyzed using SAS (version 9.2; SAS Institute, Inc, Cary, NC) and SPSS (version 17.0; SPSS Inc., Chicago, Ill).
Results
Table 1 shows the characteristics of the 806 women overall and separately by the presence or absence of recent sexual activity. The median age was 67 (range 40-99) years; 63% (503) were postmenopausal, 20% (158) reported still having menses, and 17% (143) had insufficient data to classify. The mean number of years postmenopause was 24.6 years, the mean age at menopause based on last menses was 47.7 years, and 22.4% of all women reported a bilateral oophorectomy. Overall, 30.3% reported using estrogen therapy at the time of the survey. More than half of the women had at least begun a college education, and more than 90% of the heads of household were white-collar workers. The majority of women reported at least good physical and emotional health.
Table 1Characteristics of 2002 Mailer Respondents Who Answered Question About Sexual Activity with or without a Partner (FSFI_3)
Sexual activity in the past 4 weeks was reported by half the respondents (n = 401 with vs 405 without sexual activity), 321 (80%) of whom reported having a partner. Sexually active women were on average 16 years younger than sexually inactive women group (58.7 vs 74.9 years, respectively, P <.0001) (Table 1). Overall, 79.5% of sexually active women were living with a spouse or other partner, as were 47.4% of sexually inactive women. Recent sexual activity did not vary by occupation of head of household but was less often reported by women with some college education than without. Ninety-three percent of sexually active women reported good, very good, or excellent physical and emotional health. Sexually active women were more likely than sexually inactive women to report current hormone use (P < .0001). Bilateral oophorectomy was not associated with sexual activity. In analyses stratified by quartiles of age, the likelihood of being sexually active declined with increasing age—83% of the youngest women, 64% of the second quartile, 40% of the third quartile, and 13% of the fourth quartile reported recent sexual activity.
Sexual Desire and Sexual Satisfaction in Sexually Active and Sexually Inactive Women
All women with or without recent sexual activity were questioned about their interest in sex. Forty percent (39.87%) of all women stated that they never or almost never felt sexual desire; one third of sexually active women reported low, very low, or no sexual desire. Only 3% said they felt sexual desire almost always or always, and 41% were in the youngest age group; 30% were using postmenopausal estrogen. Sexual desire was positively associated with current hormone use, sexual activity, and frequency of arousal, lubrication, and orgasm.
Most sexually active women were moderately satisfied (24%) or very satisfied (54%) with the amount of emotional closeness during sex with their partner. Emotional closeness was not related to age, current hormone use, or participant's education level. Satisfaction with the amount of emotional closeness during sexual activity with a partner was associated with more frequent arousal, lubrication, and orgasm.
All women with or without recent sexual activity were questioned about their sexual satisfaction with a partner. Approximately 64% of all women in this cohort were moderately satisfied (24%) or very satisfied (40%) with their sexual relationship with their partner. Reporting “very satisfied” was noted less frequently in the youngest women (33.5%).
Regardless of partner status or sexual activity, 61% reported that they were moderately satisfied (26.6%) or very satisfied (34.2%) with their overall sexual life.
Approximately half of sexually inactive women (48.6%) reported they were at least moderately satisfied (Table 1). For all women, the frequency of being very satisfied with sexual life increased in a graded stepwise fashion with increasing quartile of age (25.3% for the youngest women, 30.1%, 44.1 %, and 46.7% for the oldest women; P < .001).
Arousal, Lubrication, Orgasm, and Pain in Sexually Active Women
Among sexually active women, 64.5% reported being aroused most times, almost always, or always; 69% reported being lubricated most times, almost always, or always; 67.1% achieved orgasm most times, almost always, or always; and 86.4% reported discomfort or pain during vaginal penetration only a few times, almost never, or never.
When analyzed by quartiles of age, the youngest women reported the highest frequency of arousal (54.8%); however, 23.1% of the oldest women (aged 80+ years) reported arousal almost always or always; a similar pattern for satisfaction with arousal was reported (Figure 1) . Level of sexual arousal and confidence about sexual arousal followed a similar distribution. There was no significant association between arousal and current hormone use.
Figure 1Sexual arousal responses in sexually active older women (responses to questions pertaining to arousal by quartile of age in sexually active women: first quartile < 55.12 years, second quartile 55.14-68.02 years, third quartile 68.03-79.91 years, fourth quartile > 79.92 years.)
Frequency of lubrication during sexual activity decreased with age; 60.8% of the youngest women reported lubrication almost always or always compared with 28.6% of women age 80 years or more; a similar trend was reported with frequency of and difficulty maintaining lubrication (Figure 2) . There was no significant association between current hormone therapy use and lubrication.
Figure 2Lubrication responses in sexually active older women (responses to questions pertaining to lubrication by quartile of age in sexually active women: first quartile < 55.12 years, second quartile 55.14-68.02 years, third quartile 68.03-79.91 years, fourth quartile > 79.92 years.)
The youngest women had the highest frequency of orgasm (47.6%); however, 37.5% of the oldest women reported reaching orgasm almost always or always (Figure 3) . Lack of difficulty reaching orgasm followed a similar distribution and trend. The highest orgasm satisfaction was reported in both the youngest and oldest women; approximately 42% of women in the youngest age quartile were very satisfied with their ability to reach orgasm, 35.4% in the second quartile, 37.7% in the third quartile, and 41.7% in the oldest quartile (Figure 3). There was no significant association between orgasm and current hormone use.
Figure 3Orgasm responses in sexually active older women (responses to questions pertaining to orgasm by quartile of age in sexually active women: first quartile < 55.12 years, second quartile 55.14-68.02 years, third quartile 68.03-79.91 years, fourth quartile > 79.92 years.)
Less than 5% of sexually active women reported a very high or high level of discomfort or pain during or after sexual activity. Among the oldest women, 71.4% reported their level or degree of discomfort or pain as low, very low, or none during or following vaginal penetration. There was no significant association between current hormone replacement therapy use and pain with vaginal penetration.
Discussion
Half of these community-dwelling women aged 40 to 100 years reported sexual activity within the last 4 weeks. In other studies, recent sexual activity was questioned differently and in different age groups, making direct comparisons difficult. Despite differences in study design and population characteristics, a significant proportion of older women report sexual activity.
Although we report an inverse relationship between some college education and sexual activity, results from other studies linking sexual activity with college education are mixed.
most early reports in the literature described the sexual domains in terms of dysfunction; less data exist in unselected community-based samples. In the RBS cohort, frequent arousal, lubrication, and orgasm were reported by approximately two thirds of sexually active women. Although the highest frequency of arousal and lubrication was reported by the youngest women, at least 1 in 5 women aged 80 years or more reported arousal, lubrication, and orgasm almost always or always.
Low sexual desire was reported by approximately one third of sexually active women in the RBS, similar to the prevalence previously reported.
A diagnosis of hypoactive sexual desire disorder requires symptoms resulting in personal distress; we did not ask about personal distress and cannot report the prevalence of hypoactive sexual desire disorder. The youngest women in the RBS reported lower sexual satisfaction with higher sexual desire, and this could represent a higher percentage of younger women who meet the criteria for hypoactive sexual desire disorder. Low sexual desire increases with age, but distress about low sexual desire decreases with age.
In the present study, despite a correlation between sexual desire and other sexual function domains, only 1 of 5 sexually active women across all age groups reported high sexual desire. Approximately half of women aged 80 years or more reported arousal, lubrication, and orgasm most of the time but rarely reported sexual desire. In contrast with the traditional linear model in which desire precedes sex,
because sexual desire did not precede sexual arousal in most women, suggesting women engage in sexual activity for multiple reasons, which may include nurture, affirmation, or sustenance of a relationship.
Current hormone therapy was associated with sexual activity and desire but not with arousal, lubrication, orgasm, or satisfaction. Current estrogen therapy may affect sexual health indirectly by relieving menopausal symptoms or by improving how women perceive their emotional or physical health. No clinical trials have shown a causal association between estrogen therapy and the sexual function domains reported.
Because oral estrogen therapy increases sex hormone binding globulin levels, and thereby reduces bioavailable estradiol levels, oral estrogen therapy may not provide physiologic free estradiol levels. In contrast, one study reported sexual desire increases with testosterone treatment.
Some clinical trial evidence shows use of transdermal testosterone along with estrogen may increase the frequency of satisfying sexual activity in naturally postmenopausal women with hypoactive sexual desire disorder,
but testosterone therapy is not approved by the US Food and Drug Administration. Recent UK treatment guidelines recommend a multidisciplinary approach to female sexual problems and include the use of testosterone in selected patients.
the percentage of RBS sexually satisfied women actually increased with age quartile, with approximately half (47.5%) of the women aged more than 80 years reporting sexual satisfaction almost always or always. Not only were the oldest women in this cohort the most satisfied overall, those who were recently sexually active experienced orgasm satisfaction rates similar to those of the youngest quartile. Sexual relationship satisfaction also was reported by the majority of women with or without recent sexual activity. Two thirds of the sexually active women were moderately or very satisfied with their sex life, as were almost half of sexually inactive women. In this study, sexual activity was not always necessary for sexual satisfaction. Those who were not sexually active may have achieved sexual satisfaction through touching, caressing, or other intimacies that have developed over the course of a long relationship.
Generalizability in this study is limited by the socioeconomic homogeneity of the cohort. The response rate was good for this type of questionnaire, but response bias may exist because only those with the best emotional or physical health may have been sexually active or have taken time to complete the long questionnaire. The sexual activity questionnaire itself may have prompted sexual activity. Our 2002 questionnaire did not ask about the partner's use of medication for erectile dysfunction; increasing use of such medication may have altered the sexual activity available to women. Given that sexual satisfaction does not always require sexual activity, a greater emphasis on specific sources of satisfaction may be useful in the evaluation of sexual domains.
A more positive approach to female sexual health focusing on sexual satisfaction may be more beneficial to women than a focus limited to female sexual activity or dysfunction.
How would you rate your level (degree) of sexual desire or interest?
3
Over the past 4 weeks, have you engaged in any sexual activity or intercourse?
Respondents who answered no were instructed to skip to question 19.
4
How often did you feel sexually aroused during sexual activity or intercourse?
5
How would you rate your level of sexual arousal during sexual activity or intercourse?
6
How confident were you about becoming sexually aroused during sexual activity or intercourse?
7
How often have you been satisfied with your arousal during sexual activity or intercourse?
8
How often did you become lubricated during sexual activity or intercourse?
9
How difficult was it to become lubricated during sexual activity or intercourse?
10
How often did you maintain your lubrication until completion of sexual activity or int ercourse?
11
How difficult was it to maintain your lubrication until completion of sexual activity or intercourse?
12
When you had sexual stimulation or intercourse, how often did you reach orgasm?
13
When you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm?
14
How satisfied were you with your ability to reach orgasm during sexual activity or intercourse?
Respondents who do not have a partner were instructed to skip to question 20.
15
How satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?
16
How would you rate your level (degree) of discomfort or pain during or after vaginal penetration?
17
How often did you experience discomfort or pain during vaginal penetration?
18
How often did you experience discomfort or pain after vaginal penetration?
19
How satisfied have you been with your sexual relationship with your partner?
20
How satisfied have you been with your overall sexual life?
Most responses used a 5-point Likert scale. Frequency responses: almost always or always = 5 points; most times (more than half of the time) = 4 points; sometimes (about half of the time) = 3 points; a few times (less than half of the time) = 2 points; almost never or never = 1 point. Level responses: very high = 5 points; high = 4 points; moderate = 3 points; low = 2 points; very low or none at all = 1 point.
Funding: The Rancho Bernardo Study was funded by the National Institutes of Health/National Institute on Aging Grants AG07181 and AG028507 and the National Institute of Diabetes and Digestive and Kidney Diseases Grant DK31801.
Conflict of Interest: None.
Authorship: All authors had access to the data and played a role in writing this manuscript.
Obtained from a subsample of women who attended a clinic visit in 1999-2002.
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