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Abstract

The International Classification of Diseases, Tenth Revision (ICD-10), describes sexual dysfunction on the basis of the inability of the individual to participate in a sexual relationship. On the other hand, the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) describes it as the inability to respond sexually or experience sexual pleasure. Neither diagnostic manual addresses age as a contextual factor in sexual response, though DSM-5 notes that aging may be associated with a normative decrease in sexual response. In this review, we argue that the diagnosis of sexual dysfunction in the elderly should be based on age-related expectations. As examples, in older women, diagnostic criteria should factor in the considerations that vaginal dryness is associated with genital pain on penetration and with anorgasmia, as components of the genitourinary syndrome of menopause. In older men, the criteria for rigidity of erection and time to ejaculation may be unduly stringent and are not calibrated to changes in autonomic function with age.

The lack of consideration of aging physiology in diagnostic systems and the predominance of ageist stereotypes restrict the validity of diagnoses of sexual dysfunction in older adults; there is the possibility of both under and over diagnosis, based upon the attribution models of the patient and the clinician. Age sensitivity during medical training would help reduce ageist stereotyping in clinical practice. Sexual health education in older adults would help familiarize them with and relieve distress related to body changes that may be distressing and that may impact their quality of sexual life.

Keywords

Aging sexuality decade for healthy aging healthy aging late life sexuality nosology sexual dysfunction sexual health

Introduction

The tenth and current edition of the International Classification of Diseases (ICD-10)¹ outlines sexual dysfunction (F52), not caused by an organic disorder or disease, as including the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish. These are separated physically and conceptually from the organic causes of sexual dysfunction described under diseases of the genitourinary system (N40-N99).² However, despite this separation, the diagnostic guidelines go on to note that it is commonly difficult to ascertain the relative importance of psychological and/or organic factors and that, in such cases, it may be more appropriate to categorize the condition as being of either uncertain or mixed etiology.

The fifth and current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)³ similarly describes sexual dysfunctions as a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure. While the DSM-5 does not dichotomize functional and organic sexual dysfunction, unlike the ICD-10, it does go on to note that if the sexual dysfunction is attributable to another medical condition, the individual should not receive a psychiatric diagnosis.⁴

Neither diagnostic manual, however, addresses age as a contextual factor in sexual response, though the DSM-5 notes that aging may be associated with a normative decrease in sexual response. Neither manual discusses the interaction of the biological, psychological, social, cultural, or environmental factors (that are associated with stochastic aging and chronological aging) upon sexual functioning and sexual dysfunction.⁵ This raises the question of whether the current clinical guidelines and diagnostic guidelines of both manuals are appropriate for or applicable to older adults.⁶

This discussion examines the conceptualization of age-related sexual dysfunctions in the context of the sexual response cycle. It also examines the limitations associated with concepts when these are extended to aging sexual physiology. The underlying argument is that age-appropriate diagnostic guidelines⁷ could be desirable in the context of decreased expectations related to sexual performance associated with normal aging.

Disorders of Sexual Desire

The disorders of sexual desire include a lack or loss of sexual desire and sexual aversion or the lack of sexual enjoyment in the ICD-10, and female sexual interest/arousal disorder and male hypoactive sexual desire disorder in the DSM-5.^1-5

Studies in older adults in the community such as the National Social Life, Health and

Ageing Project (NSHAP)^8-10 in the USA found a decrease in sexual desire in 43% of women between 57 and 85 years of age, of whom 61% found the low sexual desire distressing. Decreased desire was observed in 28% of men between 57 and 85 years, of whom 65% found the low sexual desire distressing. Furthermore, 23% of older women and 34% of older men participating in the study reported not finding sex pleasurable. An Indian study^{11, 12} by Kalra et al,¹¹ based in a hospital out-patient department, found that 66.7% of older women reported sexual desire had reduced “very much.” In this study, 76% of women and 73% of men reported finding sex less pleasurable than before. However, in this Indian study, distress related to sexual function was not assessed.

Physiologically, a reduction in sexual desire^13-16 is seen above the age of 40 years, with a successive reduction in every decade of life thereafter, though a significant proportion of older adults continue to be sexually active as they age^17-18 and throughout their life. What is unclear is the degree to which this decline in desire is distressing and the dysfunction associated with it. The distinction of physiological decline from pathological decline remains murky. While a decline in desire must be a clinically significant disturbance to qualify for a diagnosis, the ultimate decider is the individual’s ability to participate in a sexual relationship as her or she would wish. Further, at this point the desires and expectations of the older individual must be delineated from social myths, mores, and misconceptions¹⁹ about late life sexuality.

Older persons as they age, often deem physical intimacy less important than emotional intimacy, though this is far from universal. Sexual activity in older adults more often consists of kissing, hugging, fondling, or sleeping side by side,^17-18 while foreplay and penile–vaginal intercourse usually becomes less important. An overemphasis upon the desire to engage in penile-vaginal emphasis may lead to the erroneous diagnosis^{20, 21} of lack or loss of sexual desire, even in the absence of distress about the changing patterns of intimacy with age.

On the other hand, an overtly nihilistic approach^{20, 21} to aging may lead older adults and clinicians to dismiss the inability to feel the desire even where they wish to as part of the aging process. Further, the lack or loss of sexual desire also needs to be delineated from environmental constraints¹⁸ such as the lack of privacy to the older couple, shame about the changes in appearance of the aging body, restrictions upon mobility and exercise, such as arthritis and cardiovascular disease, mental health illnesses, such as depressive disorders, and association with neurodegenerative disorders, such as movement disorders and the dementias.

Disorders of Sexual Arousal

These are covered under failure of genital response in the ICD-10 and female sexual interest/arousal disorder and erectile disorder in the DSM-5.^1-5

In the NSHAP,^8-10 39% of women faced difficulty with lubrication, and of these, 68% found the difficulty distressing. Further, 37% of male participants found it difficult to attain and maintain an erection and 90% of these found this inability distressing. In India, an epidemiological study based in a South Indian rural population by Rao et al¹² reported arousal dysfunction in 28% of women and erectile dysfunction (ED) in 43.5% of men. In another Indian study previously referred to, Kalra et al¹¹ reported that 40% of women found vaginal lubrication difficult and an impediment to sexual activity, and 28.7% of men found erection insufficient for satisfactory sexual activity.

As with disorders of sexual desire, the high prevalence in older adults is of concern, with the need to delineate physiological from pathological changes^13-16 and the wish of the individual from social mores. While arousal, unlike desire, has a definitive and easily measured clinical response which aids diagnosis, the physician must be guided by and base the diagnosis upon the importance of the decline in genital response to the older individual, a slippery ground to navigate. Genital response is slower and takes longer in older men and women, as part of the physiology^13-16 of the aging process. The diagnosis of a failure of genital response in the aging person is thus to be based upon the inability to participate in satisfactory sexual activity, with considerable interindividual variability in what is deemed satisfactory. There is also considerable variation in the degree to which the change in genital response may be distressing to the older adult, partly based on their expectations of themselves and their partner, and partly based upon the sociocultural norms.

In older women, the distinction between the pathological arousal dysfunction and the normative vaginal dryness associated with estrogen deficiency in menopause^13-14 is unclear. Further, vaginal dryness in perimenopausal older women is a frequent course of discomfort and pain during penetration, which may fall within the ambit of nonorganic vaginismus or nonorganic dyspareunia in the ICD-10 and genitopelvic pain/penetration disorder in the DSM-5. Pain during penetration is not inconsiderable in older women, occurring in 17% of women in the NSHAP,^8-10 97% of whom were distressed by this, and 8% of women in a study by Rao et al.¹² Vaginal dryness and pain during the perimenopausal years may be associated with the genitourinary syndrome of menopause and pelvic infections, a commonly overlooked cause of distress in aging women.

In older men, the normative decline in autonomic functioning, meaning that older men might take longer to obtain and maintain penile rigidity and experience a decline in penile rigidity with every decade post 40 years of age,^15-16 has to be delineated from clinically significant failure of genital response and based upon what they and their partner would consider satisfactory sexual activity. There is some data from surveys of sexual attitudes and behaviors to suggest that older men find the decline in genital response more distressing¹⁷ than older women due to the association with traditional concepts of masculinity¹⁹ and potency. An inability to account for aging physiology may occur in the excessive diagnosis of ED (one of the most common forms of sexual dysfunction) in older men. On the other hand, the perception of aging as a deteriorative process may often lead clinicians to dismiss ED in older men, leading to therapeutic nihilism. ED is also the most common form of iatrogenic sexual dysfunction^8-10 in older men, a commonly overlooked and underdiagnosed yet easily treatable condition.

Disorders of Orgasmic Function

These are covered under orgasmic dysfunction and premature ejaculation in the ICD-10 and come under female orgasmic disorder, premature (early) ejaculation, and delayed ejaculation in the DSM-5.^1-5

In the NSHAP,^8-10 34% of women and 20% of men reported an inability to climax, and 59% of women and 73% of men affected were distressed by the inability to climax. Further, 28% of men reported climaxing too quickly and 71% of men affected were distressed by this. In India, Rao et al¹² reported orgasmic dysfunction in 20% of women and 0.38% of men, the rates of ED in older Indian men being remarkably lower than in international literature. Premature ejaculation, however, was reported in 10.9% of older male participants.

Anorgasmia in Older Women

The most obvious concern with disorders of orgasmic function is the emphasis laid on orgasm²² as the end point of sexual activity. Unlike sexual desire and arousal, however, there is no clear decline in the frequency of orgasm with age, though the duration of the plateau and the frequency and intensity of contractions of the pelvic and perineal muscles in women and the ejaculatory tract in men²³ is reduced. Older women report taking longer to orgasm.²⁴ The physiology of the orgasm in the aging male is far less clear with reports of both longer and shorter times to orgasm, the frequency of association of the orgasm with ejaculation reducing with age.²³

There are differing levels of importance placed upon the orgasm²⁴ across cultures and between genders. Conventional heteronormative sexual scripts place more importance upon the male orgasm than the female orgasm.²³ 10% of women reporting never having experienced an orgasm during their lifetime.²⁵ The orgasm gap across the world is estimated to be around 53%.^24-25 Developing countries such as India appear to experience a larger orgasm gap of around 70%,²⁶ partly explained by more conservative sociocultural norms.

It is unclear what happens to the orgasm gap with age. However, the diagnosis of female orgasmic dysfunction in older women requires the presence of clinically significant distress. As is evident from data, an inability to orgasm is significantly higher in older women than in older men, though the distress around the same is significantly lower in older women than in older men. The interplay of age- and gender-related norms makes it difficult to distinguish the extent to which the reduction in the frequency and intensity of orgasms in older women is due to poor sexual technique or inadequate stimulation. The longitudinal and cohort effects, unfortunately, also mean that older women are less likely to prioritize their orgasms over their lifespan and have this consistently reinforced in sexual relationships. Thus, fewer older women are likely to perceive the inability to climax as distressing or report it. Older women are also less likely to engage in masturbation, a more reliable source of orgasm in women than partnered sexual intercourse, due to sociocultural norms.

Premature Ejaculation in Older Men

With regard to men, the concept of premature ejaculation is problematic in both the ICD-10 and the DSM-5, in differing ways.^27-29 The ICD-10 Clinical Description and Diagnostic Guidelines (CDDG) does not specify the time to ejaculation which may be considered premature. However, the ICD-10¹ Diagnostic Criteria for Research (DCR) specifies an intravaginal ejaculation latency time (IELT) of 15 s. The DSM-5,³ on the other hand, specifies a more liberal cut-off of 1 min. It also recognizes specifiers based upon the IELT (mild, less than 1 min; moderate, less than 30 s; and severe, less than 15 s). It recognizes no difference between the lifelong and acquired subtypes of premature ejaculation.

Both diagnostic systems have been criticized²⁹ by the International Society of Sexual Medicine (ISSM) for an inadequate representation of male sexual physiology. The ISSM recommends different IELT cut-offs²⁹ of 1 min for lifelong and 3 min for acquired ED. In addition to this, the ISSM also recognizes a third subtype of ED, subjective, with an IELT cut-off of 6 min. The ICD-11 has attempted to address this ambiguity by recognizing all 3 subtypes of ED in its beta draft.⁷ However, the IELT for each of these subtypes has not yet been specified.

The implications of what might appear to be a semantic difference in clinical description are enormous for older men. Premature ejaculation is the second highest sexual dysfunction^8-12 in older men (above 60 years), both across the world and in India. Prevalence rates increase by 6 to 7 fold with an increase in age (above 80 years). Based on the ICD-10¹ diagnostic criteria, the estimated prevalence of premature ejaculation is between 15% and 40% percent in older men. The more liberal cut-offs advocated by the DSM-5 and ICD-11, if applied, will increase the prevalence of premature ejaculation in older men by 3 to 4 fold²⁹ affecting 40% to 70% of older men, a statistic of considerable public health importance.

The distinction between age-related reduction in time to ejaculation and clinically significant premature ejaculation in older men is unclear²⁷ as is the frequency of associated distress.^8-12 The ILET cut-offs make no distinction^27-29 between younger and older men.

Delayed Ejaculation in Older Men

The diagnostic category of delayed ejaculation is included in the DSM-5, but not in the ICD-10. It remains the least well-defined and understood sexual dysfunction³⁰ in men, and as a consequence the least diagnosed. There are no operationalized criteria to determine when the time to ejaculation in a man would qualify as delayed, though the ISSM suggests²⁹ that since most men take between 4 and 10 min to ejaculate, clinicians may consider men with an IELT of 25 to 30 min as meeting the criteria for delayed ejaculation. The prevalence is estimated²⁹ to lie between 1% and 4% of all men with some suggestion of an increase in prevalence with age. Although there appears to be a physiological increase in time to ejaculation in most older men, the ISSM recommendations, as with premature ejaculation, do not take this into account with the diagnosis being based upon perceived distress.

The ability to hold off the orgasm during sexual activity is usually a learned sexual skill. Older couples frequently report the natural increase in time to orgasm during partnered sexual activity to be more pleasurable, though the orgasm may be less intense than in younger years. However, the increase in time to orgasm may also result in fatigue in the older couple if the orgasm is set as the end-point in sexual activity.

Despite this, 25 min to ejaculation, may be an overtly rigorous criterion for the older men than it is for the younger men.

Summary

There are several issues with regard to the nosology of sexual dysfunctions that are relevant^31-33 to diagnosis and management in older adults; as examples, desire does not need to precede arousal, orgasm does not always need to be associated with an ejaculate, orgasm does not need not be the end point of sexual intimacy, etc. The very nature and meaning of intimacy also changes with aging ,^{6, 18} as do the opportunities for intimacy available to older persons, in consonance with sociocultural norms; this could also impact on nosology.

An incomplete appreciation of these changes as well as the pressure⁶ upon older persons to stay as vigorous in intimacy as they were before can result in distress to the aging person, which is erroneously interpreted as a sexual dysfunction. Further, comorbidities and iatrogenicity are an underappreciated cause of organic or mixed etiology sexual dysfunction in older adults, and the sexual dysfunction may then be misattributed to be functional in origin or may be associated with therapeutic nihilism in health care.

The diagnostic delineation between dysfunction at different stages of the sexual response cycle in women^{31, 32} is not as obvious as in men, and this is especially true in older persons; this is because the external physiological correlates are less clear. As a result, portmanteau diagnoses, such as the female sexual interest/arousal disorder are more commonly made. Vague and ill-defined terms such as inability to participate as one would wish or respond sexually leave considerable scope for interpretation and misinterpretation, and this, again, is especially true in older persons.

The failure of lubrication and vaginal dryness in older women is associated with genital pain on penetration and anorgasmia, multiple overlapping diagnoses for the genitourinary syndrome of menopause.^{31, 32} The criterion for rigidity of the erection and time to ejaculation may be over stringent for older men and are not calibrated to the change in autonomic function with age.

These nosological limitations to the diagnosis of sexual dysfunctions in the older adults interact with ageist stereotypes³³ in the community at large and even in the medical field, in particular, and have the potential to adversely impact the diagnosis and management of sexual complaints in older adults. Further, the diagnostic criteria in the ICD-10 and DSM-5 do not take into account aging physiology with the possibility of occurrence of both under- and overdiagnosis, based upon the attribution models of the patient and clinician.

Other Issues

There are other issues that need to be considered, such as sexual functioning in sexual and gender minorities³⁴ in older adults. The nature of consent to sexual intimacy in older adults with cognitive impairment and in long-term care facilities³⁵ also merit discussion. These have not been addressed because they were considered to be out of the scope of the present discussion.

Recommendations

Sexual function deteriorates with increasing age; this is a part of aging physiology and is an incontrovertible fact. As a result, older persons as well as the clinicians who diagnose them should scale down expectations of sexual capacities and sexual functioning. This means that operationalized criteria for sexual dysfunction should be age-sensitive rather than “one size fits all.” This is important because such reconceptualization could reduce distress with and overdiagnosis and overmedicalization of normal aging processes. This, however, does not mean that clinicians should dismiss reports of sexual dysfunction in older persons as part of normal aging; rather, wherever possible, they should consider interventions that may be of help.

Diagnostic manuals must emphasize the need to differentiate a functional or organic disorder from normative aging physiology. The differentiation between a functional and an organic disorder may be moot in older adults, in whom mixed etiology often predominates. A unified concept, such as the genitourinary syndrome, may be more useful to conceptualize sexual functioning in older adults than a bewildering multiplicity of diagnoses.

Age sensitivity during medical training³⁶ would help address ageist stereotypes in clinical practice. Sexual health education³⁷ in older adults would also help familiarize them with and relieve distress about changes in the body that are often disturbing and that may impact their quality of sexual life. Addressing concerns about body image and promoting body positivity may go a long way toward mitigating some of the distress around sexuality in older adults.

Finally, not all people age or are intimate in the same way, and sexual heuristic systems must therefore have some room for flexibility.¹⁷

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Migita D’cruz

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Nosology of the Sexual Dysfunctions: Are They Appropriate to Older Adults?

Abstract

Keywords

Introduction

Disorders of Sexual Desire

Disorders of Sexual Arousal

Disorders of Orgasmic Function

Anorgasmia in Older Women

Premature Ejaculation in Older Men

Delayed Ejaculation in Older Men

Summary

Other Issues

Recommendations

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References