Redefining Intimacy: Sex, Ageing, and Emotional Connection

This week's episode has been sponsored by Oh My Bod, shifting the evolution of pleasure. Hi, this is Suzanne Noble, and you're listening to Sex Advice for Seniors. And a while back, I had on a guest called Dr. Rebecca Lahan, and she'd done this humongous presentation about Seniors and Sex. And she'd done another big presentation on values-aligned sexuality. And I think we said we were going to do seniors and sex, and then we did values-aligned sexuality. So, so we thought that we'd go and do another recording where we actually talked about what we had intended to talk about the first time, which is seniors and sex. And Dr. Lahan's a licensed psychologist. She's a certified sex therapist. She's a speaker. She's got a resume as long as your arm. I'll, I'll put the link on the bio so that I don't have to read like 4 paragraphs of stuff. But anyway, I started— she's done this amazing, amazing presentation, which I want to really dig into about older people and sexuality. So welcome to, again, to Sex Advice for Seniors.

Thank you, Suzanne Noble. I appreciate it.

Yeah. And so what was it that led you to wanting to tackle this I don't even know how many slides there were in that presentation, but it was quite significant. I mean, what is it that led you to decide that you wanted to really look at and deep dive into older people and sex?

So one of my specialty areas has always been geropsychology, which is working with elderly. And one of my other interests has been sexuality, primarily because I work with a lot of chronic pain and a lot of chronic illness and mobility issues. And so I kept seeing a lot of intimacy impact in that space with Geropsych specific to aging, the body changing, pain, surgeries, cancer, mobility with hips and joints. And so I started being asked so many times what this information was around how to really make accommodations around sexuality as we age. And I got asked to speak to other therapists about this information so that they could also be educated around how to help their clients and support them. This presentation was born and yes, it is lengthy. And it was mostly because I, I wanted to make sure that I had passed on everything that I thought was super important. And it turns out there's a lot that's important that I wanted to pass on. Yeah.

And I think one of the things that struck me is that because I'm doing a very similar presentation and it's mainly aimed at healthcare professionals, the one that I'm doing, it's aimed at young healthcare professionals, junior GPs, to try and teach them how to talk about intimacy issues with older adults. And that's one was, and so I approached it from a very different place with a different kind of audience, but I got to a very similar place when I was looking at many of the issues that you dug into, which was really not just covering some of the issues around, you know, what goes on in people's minds, but also, as you acknowledge, what goes on in their bodies and therefore how that impacts on, on and how it plays out in a whole range of different scenarios, which you know, include intimacy, but also just include basic sexual function.

Well, and those things are so tied together. If you don't feel good, you're not going to want to be sexy. If you don't have a good sense of managing pain or body image, or you're struggling with age-related changes and you feel awkward in your body and how to communicate those things, that all impacts emotional connection and intimacy. For sure.

Yeah. And also, as you acknowledged in your presentation, the impact of medication that you may be on.

Absolutely.

And I was even, I mean, I was going to ask you, what were some of the surprising results out of that? Looking at all of that, did you have any kind of big surprises when you started really digging into it? Because I know that I didn't know, for instance, about statins, although I did suspect that they might have some impact on sexual function, but I wasn't quite sure.

Yeah, same. No, that was one that surprised me. Statins can definitely affect sex hormone production and hormones are absolutely the driver behind libido and sexual functioning. So that was a really big one. Blood pressure medications is another one. There are so many cardiovascular systems that are involved in the arousal process, lubrication, erection, blood flow, nerve health. And so when we, when we're taking when we have any kind of cardiovascular issue, blood pressure medications really make a big impact to sexuality. Antidepressants for sure. I'm, I'm sure a lot of people are familiar with that creating anorgasmia, really difficult to get to orgasm. You can have arousal, but not necessarily get to that peak. And then other things that were surprising were things like antihistamines that really kind of dry out the body and, and affect lubrication. Obviously things that are sedating, things that, that it affects gut health. It can definitely affect the way that we digest food and then that affects our blood flow. And for example, it's better to have sex on an empty stomach because of that reason. It can take blood flow away from the, the pelvic region. So yeah, lots of different ways that medications can be involved that I don't think that we do a good job explaining to the individuals taking them.

No. And I, and I suspect that in some cases, and I suspect not all cases, but in some cases there are alternative medications that you can request that might not have such a significant impact on sexual function.

Yeah, definitely. There's, there's lots of more naturopathic ways to affect all of the systems in the body that can have less side effects, but you also have to be careful because some of them can have impacts on other medications. And so talking to your provider about that, but sure, there's lots of stimulant type herbs and things that can affect libido and blood flow for sure.

And one of your myths that you outlined is that seniors or older people just aren't interested in sex. And why do you think this misconception persists?

Well, I think that's a great question. And I often think why as well, because I think, you know, sexually we can be sexually active and have a healthy sexual life well into our hundreds if we are healthy. And that's really the key issue there is that a lot of individuals as they age, either they have issues with, like I said, cardiovascular issues, medication issues, mobility issues, pain issues, and libido issues. And that one is primarily because of the changes that we experience in our hormones over aging, which absolutely affects, affects the arousal process in an aging body. So I think we get into this mindset where we just accept, well, I have all these limitations, or I, I'm not as healthy as I used to be, or my body isn't working as well as I used to be. And really that's a huge opportunity for two major things. One is why are we settling for not being as healthy as possible? Because that absolutely affects our sexual experience. And then the second part of that is really starting to learn to emphasize, which I think we should be doing, you know, as soon as we learn about sex is to start emphasizing emotional intimacy and sexuality in non-genital specific ways so that we're not so locked into this all or nothing thinking about what emotional intimacy can be.

Yeah.

And I suspect also the other thing about our, our bodies is that if we're not healthy and we're a bit overweight, and then we're going to just lack confidence, and we're going to lack confidence around our bodies. I mean, I had a really interesting chat with, with a doctor called Lauren Stryker, and we were talking about libido. And one of the things that she said that really has stuck with me is about how complex libido is. It's not, you know, yes, it's driven by hormones, but it's also driven by the quality of our relationships, like the way that we communicate with our partner, how we feel about ourselves, whether or not we're exhausted or not, you know, are we getting a good night's sleep, like, you know, all a whole range of factors that goes into how we feel about sex and, and understanding how all of that plays into each other is really important because often when we go and see a doctor and we complain about low libido, the first thing, you know, they may say is, okay, let's test your testosterone. And then let's, you know, see how that the levels are looking. And then let's give you some testosterone and check you out in a few months' time and see how you're getting along without asking the questions. What's your relationship like with your partner? You know, are you happy? Do you talk about these things? Like, what does sex look like to you? What is it mean to you. And I think, as you said, it's about having a far more expansive idea around what sex means beyond penetrative sex.

Absolutely, absolutely. And there's so many factors psychologically that go into our experience of being able to be present enough to connect with intimacy. Body image is certainly one of them. Being able to recognize that anxiety and depression play a big roll around motivation and fatigue. There's definitely, if you have pain, there's, there's fear and anxiety around having sex because it can be difficult and uncomfortable. Especially if you're not communicating to, to make modifications. Stress, you know, financial strain or even loss. There's a lot of individuals who have widowed or who are separated and are moving into second or third relationships. And those emotions are still very present when we open up and become vulnerable with a new partner too.

Completely. And how do you think couples can foster this kind of emotional connection and intimacy when they're faced with age-related physical limitations?

Communication is the biggest one there. And that's, that's so scary for a lot of individuals because it's a huge vulnerability to talk about fears and insecurities or past trauma or past pain. But I think being able to, you know, discuss, create a safe space where you there's no judgment, there's just listening and understanding and, and validating so that both parties can really hear what each other's needs and desires are, and then be able to figure out what does that look like as far as how can we reasonably find compromise to meet each other's needs and really having that conversation many, many times because our desires change, our moods change, our needs change for sure.

And I think sometimes as well, I spoke to a woman who she just deals with people having sexual challenges as a result of limited mobility. So for instance, somebody might have a hip replacement operation and suddenly the positions that they were used to having sex in aren't comfortable anymore. And so she works with them on adaptations to figure out how they can still experience pleasure, but with some limited, you know, with more limited mobility. And I thought it was such a fascinating, quite niche job, but really necessary because we all do get stuck in our habits, I think, with our partners, right, where you have sex in quite predictable ways. And then, you know, something happens and suddenly you're like, oh my God, I can't do that anymore. So what am I going to do?

Right. And yeah, there's so many accommodations that, that really need to be taken into account. But again, if we don't communicate what's going on, then, then we're not able to address that. You know, considering that, that eyesight and hearing and flexibility and circulation and joint pain, those things all change across our lifetime. So, you know, avoiding prolonged positions, making sure that you've got supportive pillows or different things that can support more fragile body parts, making sure that you're, you're being mindful of thinning skin, doing any kind of rough sex or kink play, making sure that there's a lot of considerations around the aging body, utilizing lubrication if that's an issue from hormones, and, and really making sure that there's, um, those safety considerations are considered in advance so that you don't have to think about them so much in the moment.

Yeah, and I noticed that you gave a bunch of different references at the back of your presentation, which I was scanning through because I was like, ah, some of them were really familiar to me, some of the toy manufacturers and stuff, and some of them were unfamiliar to me. So now I've got a whole new list of URLs to look at because, you know, one thing I've been looking at is just, is some of the furniture, right? Like blow-up pillows, pillows, wedges, all sorts of different things that just actually make things easier on your knees, easier on your head.

Yes.

Yes.

Like, it's amazing, really, when you get something that's just supportive and does something that just makes it all easier, that everybody goes, oh, this is actually really nice now.

Exactly.

I could do this for a while, as opposed to my knees are starting to hurt. Can we please take a rest?

Exactly.

But you mentioned that hormone changes play a really big role in aging and sexuality. How did they impact men and women differently?

So that's a great question. In general, let me kind of answer what leads, what the hormones lead to, and then I'll talk about what happens that, that gets us to that point. So in female at birth bodies, there's a lot of changes around reduction of estrogen and testosterone, as you've already mentioned, which then also reduces the blood flow to the genitals. That can also decrease lubrication. As we age, because of the loss of estrogen, we get thinning vaginal tissue, which can make it easier to get injured or to get sexually transmitted diseases or to experience pain. Yeah. So the hormone changes also create differences in sexual desire and libido. There's decreased sensitivity. It takes longer to get to orgasm. And then in male at birth bodies, it's a lot of similar things, but difficulty maintaining erection. They're less hard. The reduced testosterone for sure. The reduced libido, less sensitivity, and less intense orgasms. So you hear those things and you're like, oh great, this is, this sounds amazing as far as getting older. But really recognizing again, that is your body's way of communicating that something is changing that, that needs to be addressed. Talking with your provider around what the options are, because those hormonal changes for, for, for females particularly is the declining testosterone and estrogen, and that affects libido, but it can also make changes in your sexual response cycle. It can create vaginal atrophy and dryness. It can create vaginal laxity, which is the, the ability to stretch and move. And then the emotional and physical changes that can influence wellbeing, particularly around hormones. You know, we've all, you know, seen all of the news around going through menopause or even just PMS and recognizing that those mood swings and hot flashes and weight gain and fatigue, those things are real and they're very hormone related. So one of the things that is, is interesting that a lot of people, like you even said, they get tested for testosterone, but really, you know, it's recognizing that it's really the fluctuations in our estrogen level that create the contrast of the testosterone that, that can increase our testosterone or our libido. And so a lot of the times it's more about making sure we're in balance than it is just adding testosterone. Because you don't, if they're not, if they're not balanced, you're gonna create totally different issues. So for women, you know, estrogen replacement therapy is certainly an option. Progesterone, recognizing that, that, that one tends to be highly correlated with mood stuff that's going on with sleep. Men, you know, they go through kind of 3 different menopauses, if you will. And there's the andropause, which is the reduction of testosterone. There's the, uh, adrenopause, which is the reduction of DHEA, and there's the somatopause, which is the growth hormone decline. So they may not hear, they might not experience it as such a stepwise drop as maybe women do, but they definitely start to lose the production of some of those hormones that really affect them in the similar way. So for them as well, hormone replacement therapy, sometimes for, for, um, for women or for, for men, the, the, the hormone replacement, I should say, it could be injections, patches, gels, oral, but then for women as well, it's, you know, the difference between topical, systemic, or internal. A lot of that is really just figuring out what is going on for you. And it's a bigger picture than just, yeah, let's add testosterone or, you know, it, it's diet, it's lifestyle, it's how are you eating? It's, it's, it's making sure you're getting all the right nutrients that you need for your body. It's reducing caffeine. It's making sure that you're getting enough sleep. Are you managing your stress? Are you, are you taking into account that holistic picture of health instead of just trying to, to address it with one particular thing?

Yeah.

And yet, even though HRT's been around for a while now, you'll still hear people say to me that they don't wanna take it. I mean, I didn't because I thought there was some risk of breast cancer in my family. And so I was worried about that. My mother was worried about that. So, you know, later on we, when we talked about it, we recognized that actually the breast cancer that she had, which was overcome, was geriatric. So it was very slow and it was something she didn't get till much later. So it wasn't really as high risk as we thought, but I think these kind of myths still persist. And I still hear lots of women tell me that they're afraid of going on HRT. What What do you think that's about?

Yeah, I, I think that there's been some studies who early on that really indicated that there were increased risks for things like breast cancer and heart disease and stroke, but I, there is so much research that has come out since then that says that the risks are actually relatively small in, in the larger context. So if it's really about how much are you suffering, what do you need for a quality balanced life? What is that gonna be in the most conservative approach possible? But that overall, and then obviously what is your family history and your risk, but that overall the risk is, is small enough that if it's not worth suffering, if you can reduce some of that.

Yeah, I agree. But I think there are still some healthcare professionals themselves who still sometimes avoid putting women on HRT just because of those perceived risks.

But let's move on to one of my favorite topics, which is the fact that STIs have gone up amongst this age group. And, you know, I don't think that there's enough awareness around that, frankly. And I, I'm curious to know what steps you think we should be taking to increase the awareness of STIs amongst over 50s.

Yeah.

You know, it's interesting. I hear that one a lot. And I think, I think one of the biggest, the reasons that it's one of the biggest myths is that when we are older and we've gone through menopause, that we no longer can get pregnant. And so you don't need to use any kind of birth control. But the reality is that you can still get an STI. And, and that is really one of, I think, the biggest issues is that a lot of individuals just stop using any kind of protection for that. You also have to consider that because of the, the thinning skin and the vaginal atrophy and the, the reduction of lubrication, the body can have micro tears a lot easier and you can get, you know, HIV a lot easier. You can get STIs. And so I think that there's this belief that we're kind of protected around pregnancy, but we don't think beyond that. Yeah.

I mean, I, I see myself that lots of older men, because we didn't grow up during an age where we were scared, you know, the HIV scares that Gen Xers went through just as they were coming into their sexual kind of selves, we'd already gone beyond that.

So I remember when all of that was happening, like in the '80s, my friends in on the West Coast in San Francisco were calling me up warning me about, you know, HIV and everything, and I said, oh, you know, I don't know if— is it really that big a deal?

Is it a big—

of course, then friends of mine started dying, so I, so I know that it definitely was, but I still hear a lot from men, I don't get on with condoms, you know, I just, I just, I just can't wear them, I just don't get on with them. I mean, I must say, not as many as as you would think, but I do think amongst older men, there is somewhat still of a stigma around, around wearing condoms, even though condoms have, you know, the materials now used in condoms are really, really highly sensitive, super thin. I've just noticed that Durex has just put out one that's like almost nothing, you know, it's, they're amazing, but And still you still get, I still get the same reaction.

Like, oh no, you know, we don't need to do that.

I mean, but as you point out, we do, because it's actually a big problem now. Like the numbers are not going down.

Yes. And actually there's, there's a lot of indicators that STIs and HIV are spreading the highest in assisted living and skilled nursing facilities. Yeah, I know.

But one of the very, very first interviews I ever did on this podcast was a woman who works on the weekend in care homes. And she was saying that one of the biggest challenges that they have is that in some cases, people become very hypersexual in, in these, you know, I think dementia, sometimes people become very, very sexual. And as a result of that, either they're trying to get off with each other, right? And so there's, there's a kind of whole thing around people in cognitive decline combined with unsafe sex, right? Plus untrained staff who don't know how to deal with any of this stuff. So they're just freaking out because they open up the door and, you know, these people are going at it and they're like, and typically she said what happens, which is very, very sad, is typically they get taken up, they get, they get pulled apart. And they get put in different areas of the facility so that they can't see each other because they don't know how to deal with sexual behavior in this age group combined with cognitive decline. Sometimes this woman said she smuggles sex toys into the care home so that they can just like get on with it. Yeah.

And that's such a shaming response. And yet you're right, you know, with with any kind of memory or cognitive issue or dementia, consent is really, really big thing there. And it's really hard to define that based on somebody's cognitive status if it's changing frequently. But, but that again, we're back to communication. It's, it's really about making sure to understand somebody's decision-making in that moment.

Yeah. And, but it's, it's very, again, I think it's, it's really, really complex. And then one of the things that you also talked about that I don't really talk about, and I want to talk more about, is just people who aren't heterosexual, who are LGBTQ. There seems to be so little aimed at that group of people around sex, older, older gay people. And how do you think we can really better support those people in addressing their sexual health needs?

Yeah, I think, you know, it's the— there are a lot of really unique needs in that population, but also it's the same things for everyone around sexuality. And it's really about advocating around consent, around safety, around education, around pleasure, you know, making sure, particularly in the gay community, there's a lot more typically domestic violence. And so, you know, making sure that there's education around intimate partner violence and really it goes back to education and communication. 100%. Yeah.

And I think also there's, there are many people at this age who are thinking, I mean, I talk a lot about just about redefining what a relationship might look like. And there are people who perhaps want to experiment or have always had the desire to have same-sex relationships, but who haven't been able to because of the circumstances that, you know, they've been brought up in, maybe societal pressure, maybe family pressure, religious upbringing, all sorts of things that contribute to, you know, what ultimately sometimes happens in our relationship where we end up with somebody that we didn't particularly want to be with, but we feel like, well, you know, we feel compelled to pair up because of just various pressures. How do you think we can better support those people in terms of enabling them to feel confident about making choices that may be outside the realms of what they would've considered to be traditional before, or normal?

Yeah, I, I feel like there is a, a great deal of consensual non-monogamy in that space, and there's a lot of open relationships and I think that being able to recognize you have to pay attention to what feels appropriate to you. You have to be able to communicate what your fears are. You have to be able to communicate ground rules that make you feel safe in your relationship and expectations. And then there has to be frequent check-ins around how is this working for you? How did that feel for you? Okay. That didn't feel good, but why? That doesn't mean it's a no. But let's talk about that. And oftentimes that's really exploring just that list that you just described. What, what are the familial patterns? What are the core beliefs? What are the religious influences? And really getting to the core of what is your value system? And is the value system that you're making your choices on now based on outdated scripts that were handed to you? And at this point in your life, are you able to make space to say, this is what's coming up for me, but maybe let me, really look at why and what is it I would like it to look like. And then how can I start making choices that move me in that direction? Or how can I clarify the things that, nope, these are really still my core beliefs and I want to have better boundaries around them. And so, you know, being able to work with someone to help them really do that deep dive into their family of origin influences, their cultural influences, their core beliefs so that whatever they decide, and there's no wrong or right, and it's different for everybody. And we can use one term and it looks different for 5 different people. It's really really about paying attention to what feels authentic for you and your partner. And how are you guys making choices that are moving you in that direction?

And one of the things that strikes me as we've been having this conversation is I feel there's a massive opportunity to take this talk beyond the world of your sex therapists and the community in which you normally would give this kind of talk and host it in retirement communities, senior living centers. I looked at this and I was like, this This is like a significant piece of work presentation that you gave, and it really covered such a vast area. And we've only just touched on, you know, just a handful of topics. And there was so much richness in that presentation. And I thought it shouldn't really just be sitting in a Google Drive somewhere. Are you— have you got any plans to do anything else with it that's actually more aimed at these, you know, the people to whom you're referring.

Maybe a fraction of what we've talked about today. Our last talk, we talked about values-aligned sexuality, and that's the piece that we, we just touched on. How do you really do that deep dive into what your influences are around sexuality? And so I'm currently in the process of publishing a book on that topic. So maybe this will be book 2.

Yeah, maybe we should co-author that together because, you know, I think that It's certainly, you know, as I said to you before the recording, I've started thinking about writing something similar and it's, and it's because it is a rich topic and it is because it's so needed. And as we've discussed, most of the issues that people face could be overcome either through just good communication, a healthcare professional that knows how to listen, a sex therapist that's understanding, someone who actually can can support you to have the kind of sex and relationship that benefits you the most. And, and it's all available. It's just not available, it seems to me, in one place. That's what, that's the, that's what I've discovered. Except of course here.

Well, let's do it. Let's figure out how to make it more available. Yeah.

Anyway, Rebecca, it's been so nice chatting with you again. And I don't know if you'd make any of this material available to, to our listeners or if there's any other resources that you think I should be signposting them to, because I'd love to just be able to do that. Otherwise I'll just send them to your website.

Yeah, this, this presentation was more, I think, clinical than just kind of the, the average audience for sure. But, but I definitely can put together maybe a summary and post it on my webpage or my socials and you can find me everywhere at drrebeccalahan.com.

Thank you very much and have a lovely day.

Thank you so much.