Dr. Kapila Ranasinghe, Consultant psychiatrist, National institute of mental health

1. Dr. Kapila Ranasinghe
Consultant psychiatrist
National institute of mental health

2. 
Human beings are
actually never too old to
enjoy a happy and
healthy sex life

3. 
Frequently misunderstood
Neglected and Ignored
Disapproved by others
Sexuality in elderly

4. Providers:
Are subject to myths and attitudes
of sexuality and aging.
May be insensitive to older
adults needs.
Don’t know how to manage sexual health
issues.
Experience discomfort in managing
sexual issues.
Health Care Provider
Barriers to Sexual Health in Older Adults
A study of 100 patients aged 39 to 86
and their health care providers
revealed that less than 10% of
providers asked patients about
erectile
function, although over 90% of
patients were interested in treatment
(Chitale, et al., 2007)
(Chitale et al., 2007)

5. 
Older Males
 May fear about the loss of sexual abilities
Older females
 may fear their interest is undignified and
disgraceful
Sexuality in elderly

6. 
 Sexuality is an integral part of the personhood of every human
being in all societies.
 Sexual rights are human rights related to sexuality;
 Sexual rights are universal, interrelated, interdependent and
indivisible;
 Sexual rights protection and promotion should be part of the
daily existence of all individuals;
 Sexuality should be recognized as a positive aspect of life
Joys of Sex: Rights of Older Adults

7. 
 Physiological
 Pathological
 Behavioural
 Psychosocial
- changes in old age can affect sexual functioning
Factors affecting the sexual
functioning in elderly

8. 
 Decline in libido
 Increased time for arousal
 More rapid reversion to pre-arousal state
 Poor quality of erection in males
 Reduced vaginal lubrication in females
 Poor quality orgasms
 Prolonged refractory period
Changes in sexual cycle

9. 
 Changes in elderly women
 reduced size of vagina & vulva
 decreased vascularity & secretions
 thinner, more lax vaginal walls
 atrophic vaginitis common
Physical changes in genitalia

10. 
 Menopause
 Andropause
 Dementia
 Chronic illnesses
 Sexual abuse
 Problematic sexuality
Important topics

11. 
 ? HRT (local and oral)
 lubricants
 education of woman & partner
Menopause

12. 
 Physiological factors
 Psychological factors
 Social and Behavioural factors
Premature Ejaculation is less
Erectile dysfunction

13. 
 Barriers to intimacy:
 Agnosia and other neurological features
 Difficulty in identifying social cues
 Sexual disinhibition
 Caregiver stress
 Depression (s)
Dementia

14. 
 Cardiac disease
 stroke
 COPD
 Diabetes
 Arthritis
 Surgery
 Endocrine Disorders
Physical illnesses affecting sexual
function

15. 
Issues
Sexual abuse

16. 
Problematic sexuality
Sexually inappropriate behavior and sexual disinhibition, in a clinically significant
level of desire to engage in sexual behavior.
 Sexual behaviors of severity and/or duration that cause distress,
disturbance or suffering for close relationships and caregivers.
 Persistent, uninhibited sexual behaviors directed at oneself or
inappropriately at others
(Nagaratnam & Gayagay, 2002) (Black et al., 2005)
(Johnson et al., 2006) (Wiseman et al., 2000) (Wick et al., 2005)

17. 
 Anxiety
 Grief
 Depression
 Late onset Psychosis
Psychiatric illness affecting sexual
functioning

18. 
Assessment of sexual health is the first step in developing a
plan of care to fulfill sexual needs of older population.
 Health history & review of systems
 Drug review
 Physical assessment
 Assessment for cognitive impairment and impact on sexual health
decision making
 Labs - ? Testosterone levels
 CT/MRI ? For hypersexual behaviors
Assessment of

19. 
 … be open-minded and concerned:
Don’t assume there are no concerns
ask direct questions about activity & attitudes
answer honestly
Don’t evade sexual concerns
Suggestions to help talking about it

20. 
 Consider screen for testosterone,highest level in AM
 if low, check FSH, LH, prolactin
 could consider Tx for libido problems
 not likely great for lost vigor and soft body!
How to answer patients’
questions?

21. 
1) Promote a healthy lifestyle.
2) Compensate for normal age-related changes.
3) Manage pathological diseases that impact sexual
health.
4) Review medications that impact sexual health.
5) Modify environment to facilitate sexual health
functioning.
Management of
Sexual Health Needs

22. 
 Testosterone given IM to 13 men 57-76 years old with low serum
testosterone
 increased lean body mass but no change in % body fat, grip strength,
bone parameters
 increased PSA
 less clear benefit than in younger men
If it works for young men can it
work for older men?

23. 
 Oral testosterone- serious hepatotoxicity
 parenteral- may cause fluctuation in levels
 transdermal- scrotal or non-scrotal
 more physiological levels
 scrotal patch causes high DHT
Tx options they might read about on
the Internet?

24. 
Compensate for Normal
Aging Changes
The use of oral erectile agents such as
agents such as sildenafil Citrate
(Viagra®), vardenafil HCL
(Levitra®), and tadalifil (Cilalis®)
have greatly aided the onset of ED
that occurs with aging.
There are a number of erectile
agents available in the form of
injectable treatments. These are
effective treatments for ED,
however some are preferred more
by patients than others related to the
extent of pain from the injections.
(Wespes et al., 2007)
(Shah et al., 2007)

25. 
Compensate for
Normal Aging Changes
 Provide patient teaching on normal aging changes on sexual
function and image.
 Discuss need for longer fore-play arousal time to compensate for
normal aging changes.
 Consider alternative forms of intimacy when sexual intercourse is
too uncomfortable or not possible.
 Use it or lose it.

26. 
Depression & Sexual Health
A sample of 30 depressed patients with a mean age of 52 was randomized to
receive either T enanthate (testosterone) 200 mg or sesame-seed oil (placebo).
Self-reported sexual functioning improved in both groups, but no significant
differences were found between groups
CATCH 22
• Treatment of depression may help to improve libido and
sexual dysfunctions such as orgasmic disorders.
• However, medications to treat depression, often impact
sexual function by lowering libido and causing orgasmic
disorders.
(Siedman & Roose, 2006)

27. 
Pharmacological Treatment
of Hypersexual/Problematic sexual Behavior
 Controversial, ethical issues
 Hormonal agents – decrease testosterone
 Anti-androgens
 Side effects include sedation, weigh gain, fatigue, hot and cold flashes, depression, loss of
body hair and mild diabetes.
 Gonadotrophin-releasing hormone
 side effects associated with these medications include hot flashes decreased erectile function
and libido and irritation at injection site.
 Estrogens
 risk of cardiovascular side effects as well and increased fluid retention, gastrointestinal effects
require caution.

28. 
Thank You