Sexual dysfunction and ageing:
Multidimensional perspectives

Presentation guide and supplementary notes

Eddy M. Elmer and Lee Dall'O, R.N.

Simon Fraser University, Fall 2001

Objective

This presentation aims to provide a broad overview of the multi-faceted topic of sexual dysfunction in the later years. Both sexual behaviour as well as sexuality will be discussed, in the context of biological, psychological, and socio-cultural factors. A distinction will be made between normal changes in sexual functioning in later life and disordered sexual functioning in later life.

Defining terms

DSM-IV divides sexual disorders into 3 categories:

1. Gender Identity Disorder
2. Paraphilias
3. Sexual Dysfunctions

This presentation will focus only on the third category of sexual disorders.

Sexual dysfunction as defined by DSM-IV: "A disturbance in the processes that characterize the sexual response cycle or by pain associated with sexual intercourse" (p. 493).

The sexual response cycle (to be discussed shortly) is influenced by numerous factors that are part of the more general phenomenon of "sexuality". In this presentation, we will use Aron & Aron's broad definition of sexuality: "the constellation of sensations, emotions, and cognitions that an individual associates with physiological sexual arousal and that generally gives rise to sexual desire and/or behavior."^1,2

ICD-10 definition³.

Why is sex important?

• sex is as important for older people as it is for the rest of us:

1. it is what makes us human
2. is part of who we are
3. lets us connect with others
4. is pleasurable

• we note, however, that sex itself is not an "essential" for healthy ageing⁴
  
  
  

History of sexology: Propagation of misinformation and dearth of quality research

• the history is important in this field
• Masters & Johnson: "Can that one facet of our lives, affecting more people in more ways than any other physiological response other than those necessary to our existence, be allowed to continue without benefit of objective, scientific analysis?"⁵
• misinformation by pioneers:

• French physician Tissot
• Havelock Ellis⁶
• Von Krafft-Ebing⁷
• Freud⁸; but did draw attention to our human sexuality!
• few cross-cultural studies at time to discover that sexual behaviour is very varied
• led to significant cohort⁹ attitudes¹⁰

• remedied to varying degrees by researchers such as:

• Kinsey^11,12: older people do have sex
• Masters and Johnson^13,14
• Gagnon and Simon: introduction of "scripting" theory^15,16

• dearth of research on sexuality in later years; research still exploratory; few theoretical perspectives
• Sex in America study¹⁷, one of largest, stops at age 60
  
  
  

A caution on the research: Ongoing methodological concerns

• epidemiology:

• few community studies
• statistics often from clinics only

• surveys and interviews:

• non-differentiation between different types of "sexual activity"¹⁸
• differing definitions: confusing/ambiguous
• biased samples
• capturing subtle and complex phenomenon
• questions may be "leading"
• researcher demand characteristics in interviews; leading; Kinsey problem
• justification of sexual activity
• lieing, boasting, timidity
• answering questions as older people thinks is appropriate (e.g. cultural myths may "contaminate" responses)
• often no cross-validation with partners
• not answering certain questions questions¹⁹: privacy issues, cultural influences
• recall problems
• but, surveys still a good tool for population studies, and interviews a good adjunct

• ground-breaking contemporary studies: innovative, but problematic:

• Kinsey's research
• Redbook Survey²⁰
• The Hite Report²¹
• Janus study²²
• many studies look only at behaviour, not desire, etc.²³
  
  
  

Normal human sexual response cycle

Graph by Peter Sándor Gardos,
http://sexuality.about.com/library/weekly/aa062998.htm

• 4 phases:

1. excitement/arousal
2. plateau
3. orgasm
4. resolution

• phases timed differently between sexes
• note refractory period and gender differences
  
  
  

Normal sexuality in later life

• Masters and Johnson's two necessaries²⁴:

1. Reasonably good state of general health
2. Having an interested and interesting partner
   
   
   

Continued performance

• older people still have sex (and often a lot of it!)
• community sample of sexually active married individuals continuing to have intercourse:

Taken from Diokno, A.C., Brown, M.B., & Herzog, A.R. (1990). Sexual function in the elderly. Archives of Internal Medicine, 150, 197-200. In: Barlow, D.H., & Durand, V.M. (1995). Sexual and gender identity disorders. In D.H. Barlow & V.M. Durand (Eds.), Abnormal psychology (p. 415). Pacific Grove, CA: Brooks/Cole.

• some subgroups of older people enjoy it a lot and want to learn more!; "Remarkably robust sex life. . .by both the men and the women, even until advanced old age"²⁵
  
  
  

Normal physical changes in sexual response cycle in old age

From Ebersole, P., & Hess, P. (1990). Toward healthy aging. Human needs and nursing response (3rd ed., p. 442). St. Louis: Mosby.

• generally:

1. sexual activity drops, but still occurs at significant rates
2. erections become increasingly difficult as men get older; lubrication in women
3. age per se is not a cause of sexual dysfunction
4. decrease in sexual activity generally correlated with decreases in mobility and presence of other diseases
5. among the strongest predictors of sexual satisfaction²⁶:

1. being sexually active
2. good mental health
3. good general functional status

• menopause seems to have effect on desire only in minority of women (Alington-MacKinnon and Troll: "The mythology surrounding the menopause is based less on the reality of the female experience than on the sexist interpretations of the female experience" by male physicians²⁷)
• so, non-hormonal physical change, as well as psychosocial factors may be more important predictors of desire
• 5% of males may experience male climacteric²⁸
  
  
  

Normal changes in interpersonal relationships

• continued movement from passionate love to companionate love²⁹
• continual need to accommodate partner's physical changes, needs
• partner availability (and note: social factors make it harder for women to find partners)
• symbolic interactionism: a way to conceive these changes³⁰
  
  
  

Sexual dysfunction disorders

• couples can accommodate to normal changes in ageing³¹
• where they cannot, dysfunction occurs and may require clinical intervention
  
  
  

Introduction to the sexual dysfunctions

• review definition of "dysfunction" on p. 1
• to be classed as disorders, sexual problems must:

1. be persistent or recurrent, and
2. cause distress or interpersonal problems, and
3. be considered problematic even when taking into account normal lifespan changes in sexual functioning and what is considered to be the individual's own, regular level of sexual functioning

• all sexual dysfunctions further specified as:

1. Due to psychological factors
2. Due to psychological factors combined with a general medical condition; note: DSM-IV: "This subtype applies when 1) psychological factors are judged to have as role in the onset, severity, exacerbation, or maintenance of the Sexual Dysfunction; a 2) a general medical condition or substance use is also judged to be contributory but is not sufficient to account for the sexual dysfunction. If a general medication condition or substance use (including medication side effects) is sufficient to account for the sexual dysfunction, Sexual Dysfunction Due to a General Medical Condition and/or Substance-Induced Sexual Dysfunction is diagnosed."
   
   
   

The specific disorders and their implications in older adults

Organisational chart

From Wincze & Carey, in: Barlow, D.H., & Durand, V.M. (1995). Sexual and gender identity disorders. In D.H. Barlow & V.M. Durand (Eds.), Abnormal psychology. Pacific Grove, CA: Brooks/Cole.

Descriptions and implications in seniors

Assessment issues, especially for older adults

• general assessment procedure
• good clinical judgment needed³²: what is "persistent", "recurrent", "distressing"?
• how does one quantify "sexual desire?"^33,34
• embarrassment
• outmoded/confusing terminology for older person
• "I don't know what an orgasm is or if I've ever really had one before"³⁵
  
  
  

Etiology of sexual dysfunctions: Later life issues

The following causes can all combine interactively to cause sexual dysfunctions. In most cases, sexual dysfunctions are due more to 1.) medical conditions or 2.) psychological factors combined with medical conditions than to psychological factors exclusively.

Medical conditions and procedures

• stroke
• spinal cord injury
• prostatectomy
• complete hysterectomy³⁶ (ovarian removal is not preventative³⁷)
• STD and non-STD infections
• abnormal androgen levels

Chronic conditions³⁸

• hypertension
• cardio-vascular diseases³⁹ (incl. arterial insufficiency, venous leakage)
• high serum cholesterol
• neuropathy
• multiple sclerosis
• diabetes (50-70% male diabetics have significant ED)⁴⁰
• osteoarthritis
• chronic pain (myalgia, neuralgia)
• chronic fatigue
• prostate difficulties
• urinary incontinence and other urinary problems
• uterine prolapse
• dementia
• congenital sexual problems (impact may change over life course)
  
  
  

Prescription drug use and seniors

• can interfere with normal sexual functioning^41,42
• antihypertensives⁴³, CVD drugs, etc.
• pain medications: opioids
• psychotropics:

1. anti-depressants (Wellbutrin, Serzone alternatives)
2. sedatives
3. anxiolytics
4. antipsychotics

• antihistamines
  
  
  

Alcohol

Smoking⁴⁴

Psychological factors among seniors

• perceptions of changes in body image
• fear after heart attacks, near death
• visible changes after medical procedures (e.g., mastectomy, colostomy bags)
• personality traits⁴⁵ in general
• anxiety⁴⁶ vs. distraction^{47, 48}
• panic attacks
• depression

Possible psychological consequences of sexual dysfunctions themselves (which may also perpetuate the dysfunctions)

• loss of self-esteem
• poor self-image
• anxiety
• depression
  
  
  

Interpersonal factors⁴⁹

• stresses for caregiving spouse⁵⁰
• personality/mood changes in a partner, esp. due to dementia, etc.
• dysfunction in one partner may lead to numerous relational difficulties
  
  
  

Socio- cultural factors, cohort effects

• taboos on sexuality—at any age (e.g., link with vaginismus⁵¹)
• sex in older age "perverted"
• "inappropriate" for older people to have sex
  
  
  

Treatments for sexual dysfunctions⁵²

• seniors may approach these treatments differently than younger people; we must be aware of this to tailor these treatments for them
  
  
  

Psychoeducation

• psychoeducation more powerful for sexual dysfunctions than for any other disorders
  
  
  

Psychosocial treatments

• the Masters & Johnson approach (Dual Sex Therapy), including:
• non-demand pleasuring & sensate focus
  
  
  

Specific sexual techniques

• masturbation skills for both men and women
• Kegel exercises: myth?
  
  
  

Hypnotherapy

Behaviour therapy

• systematic desensitisation
• assertiveness training
• with or without partner
  
  
  

Group therapy

Analytically- oriented sex therapy

Medical treatments

• limited application; not enough research
• anxiolytics
• anti-depressants (note also benefit of side-effect, esp. with Paxil and Desyrel)
• perhaps hormone treatments, testosterone & estrogen creams
• oral medications: sildenafil (Viagra), for male or female
• constrictive penile rings
• vacuum erection devices
• transurethral therapy: e.g., alprostadil pellets (MUSE)
• vasoactive penile injections: e.g., alprostadil (Caverject/Edex), phentolamine (Vasomax), apomorphine (Spontane), papaverine
• vascular surgery (rare)
• implants: 1) malleable, or 2) inflatable
  
  
  

Special issues

• homosexuality⁵³: dysfunctions occur also in gay men; two men may experience different dysfunctions than heterosexual couple
• resurfacing of rape⁵⁴ and incest⁵⁵ memories
• sexual activity in institutional settings⁵⁶
  
  
  

Concluding thoughts

• older people's sexual attitudes can change⁵⁷
• changing public attitudes⁵⁸
• changing family members' attitudes⁵⁹
• more sex education across the lifespan—and also for caregivers⁶⁰; psychoeducation is more potent treatment for sexual dysfunctions than for any other disorders
  
  
  

Respecting the sexuality of older adults

From Witter DuGas, B. (1993). Healthy life-styles. In A.C. Beckingham & B. Witter DuGas (Eds.), Promoting healthy ageing: A nursing and community perspective (p. 152). St. Louis: Mosby.

Discussion questions

1. Why are sexual dysfunctions listed in the DSM-IV, a psychiatric disorders manual?
2. Is the heavy promotion of Viagra helpful for older people's sexuality?
3. Should older people be allowed to have sex in institutional care settings?
4. Should we spend more money on sexology research in general, and elder sexuality research specifically?
   
   
   

Self quiz

Historical and methodological questions taken from Robert Koch Institute Archives for Sexology (n.d.). Chronology of sex research. [On Line]. Available: http://www2.hu-berlin.de/sexology/

Endnotes

1. Aron, A. & Aron, E.N. (1991). Love and sexuality. In K. McKinney & S. Sprecher (Eds.), Sexuality in close relationships. New Jersey: Lawrence Erlbaum Associates.
2. This definition is sufficiently broad that it allows us to think of dysfunctions not merely in biological terms (e.g., decreased physical functioning, implications of medical conditions and drug use), but also in terms of psychological factors (e.g., implications of personality traits, changing sexual self-image, gender roles, anxiety, depression) and social factors (e.g., implications of attitudes towards sexuality, sanctioning of sexual behaviour in institutions).
3. World Health Organization. (1993). International classification of diseases and related health problems (10th rev.). Geneva: Author.
4. Thomas, L.E. (1982). Sexuality and aging: Essential vitamin or popcorn? The Gerontologist, 22 (3), 240-243.
5. Masters, W.H., & Johnson, V.E. (1966). Human sexual response. Boston: Little, Brown.
6. Ellis, H. (1906). Studies in the psychology of sex. New York: Random House.
7. Von Krafft-Ebing, R. (1965). Psychopathia sexualis. New York: Bell Publishing. (Original work published 1886).
8. Freud, S. (1962). Three essays on the theory of sexuality. Trans. J. Strachey. New York: Avon. (Original work published 1905).
9. Riley, M.W., Foner, A., & Waring, J. (1972). Age and society. Vol. 3: A sociology of age stratification. New York: Russell Sage.
10. A vivid example of this is the popular attitude towards masturbation held in the early 19th century. In their book Sex in America: A definitive survey, Michael, Gagnon, Laumann, and Kolata (1995) write about such best-selling sex authors as Sylvester Graham, inventor of the graham cracker, who counselled in his 1834 book, A Lecture to a Young Man, that masturbation could turn a young boy into "a confirmed and degraded idiot, whose deeply sunken and vacant, glossy eye and livid shriveled countenance, and ulcerous, toothless gums, and fetid breath, and feeble, broken voice, and emaciated and dwarfish and crooked body, and almost hairless head—covered perhaps with suppurating blisters and running sores—denote a premature old age! a blighted body—and a ruined soul!" (quoted in Michael et al., p. 160).
11. Kinsey, A.C., Pomeroy, W.B., & Martin, C.E. (1948). Sexual behavior in the human male. Philadelphia: Saunders.
12. Kinsey, A.C., Pomeroy, W.B., Martin, C.E., & Gebhard, P.H. (1953). Sexual behavior in the human female. Philadelphia: Saunders.
13. Masters, W.H., & Johnson, V.E. (1966). Human sexual response. Boston: Little, Brown.
14. Masters, W.H., & Johnson, V.E. (1970). Human sexual inadequacy. Boston: Little, Brown.
15. Gagnon, J.H., & Simon W. (1973). Sexual conduct: The sources of human sexuality. Chicago: Aldine.
16. Gagnon, J.H. (1990). The explicit and implicit use of the scripting perspective in sex research. Annual Review of Sex Research, 1, 1-43.
17. Michael, R.T., Gagnon, J.H., Laumann, E.O., & Kolata, G. (1995). Sex in America: A definitive survey. New York: Warner Books.
18. Wiley, D. & Bortz, W.M.II. (1996). Sexuality and ageing-usual and successful. The Journals of Gerontology, 51, 142-150
19. Matthias, R.E., Lubben, J.E., Atchison, K.A., & Schweitzer, S.O. (1997). Sexual activity and satisfaction among very old adults: Results from a community-dwelling medicare population survey. The Gerontologist, 37 (1), 6-14.
20. Tavris, C., & Sadd, S. (1975). The Redbook report on female sexuality. New York: Delacorte.
21. Hite, S. (1976). The Hite report. New York: Dell.
22. Janus, S.S., & Janus, C.L. (1993). The Janus report on sexual behavior. New York: John Wiley and Sons.
23. Matthias, R.E., Lubben, J.E., Atchison, K.A., & Schweitzer, S.O. (1997). Sexual activity and satisfaction among very old adults: Results from a community-dwelling medicare population survey. The Gerontologist, 37 (1), 6-14.
24. Masters, W.H., & Johnson, V.E. (1966). Human sexual response. Boston: Little, Brown.
25. Wiley, D. & Bortz, W.M.II. (1996). Sexuality and ageing-usual and successful. The Journals of Gerontology, 51, 142-150
26. Matthias, R.E., Lubben, J.E., Atchison, K.A., & Schweitzer, S.O. (1997). Sexual activity and satisfaction among very old adults: Results from a community-dwelling medicare population survey. The Gerontologist, 37 (1), 6-14..
27. Masters, W.H., Johnson, V.E., & Kolodny, R.C. (1988) Sex and human loving (p. 179). Boston: Little, Brown. (Revised edition of Human sexuality, 2nd ed.)
28. Masters, W.H., & Johnson, V.E. (1966). Human sexual response. Boston: Little, Brown
29. See Hendrick, S.S., & Hendrick, C. (1992). Romantic love. Newbury Park: Sage Publications.
30. Blumer, H. (1969). Symbolic interactionism: Perspective and method. Berkeley, CA: University of California Press.
31. Wiley, D. & Bortz, W.M.II. (1996). Sexuality and ageing-usual and successful. The Journals of Gerontology, 51, 142-150
32. See Wincze, J.P., & Carey, M.P. (1991). Sexual dysfunction: A guide for assessment and treatment. New York: Guilford Press.
33. Leiblum, S.R., & Rosen, R.C. (Eds.). (1988). Sexual desire disorders. New York: Guilford Press. [Good discussion of assessment of sexual dysfunction].
34. Kaplan, H.S. (1979). Disorders of sexual desire. New York: Brunner/Mazel. [Beyond simple sexual difficulties, and into the more relevant clinical situations in which individual dynamic and interactional difficulties disrupt sexual functioning.]
35. For clinical purposes, a sound definition may be as follows: "The climax of sexual pleasure. The culminating phase of the human sexual response, characterized by a quick succession of muscular contractions, and followed by general physical relaxation. Orgasm is a highly complicated physical process, usually accompanied by involuntary movements, sounds, and gestures, such as convulsions of the body, groans, and sighs. Orgasm can make the sexual partners oblivious to their surroundings and even to each other. In fact, it could be said that during orgasm they deeply feel and forget each other at the same time. In the male after puberty, orgasm is usually accompanied by an ejaculation of semen. Orgasm in females is, in principle, the same physical reaction with the same muscular contractions, although only in very few women are the paraurethral glands developed enough to produce a prostatic fluid that can be ejaculated. There is a belief that the most perfect coitus is one that results in the simultaneous orgasm of both partners. However, this can be a dangerous ideal likely to put unnecessary pressure on the partners. Therefore, it should not be considered the decisive criterion for satisfactory intercourse or a happy sexual relationship." Taken from: Robert Koch Institute Archives for Sexology (n.d.). A critical dictionary of sexology. [On Line]. Available: http://www2.hu-berlin.de/sexology/
36. Carranzalira, A., Murillouribe, N.M.., Trejo, J., et al. (1997). Changes in symptomatology, hormones, lipids, and bone density after hysterectomy. International Journal of Fertility and Womens Medicine. 42 (1), 143-147.
37. Loft, A., Lidegaard, O., & Tabor, A. (1997). Incidence of ovarian cancer after hysterectomy: A nationwide controlled follow up. British Journal of Obstetrics and Gynaecology 104 (11), 1296-1301.
38. Schover, L.R., & Jensen, S.B. (1988). Sexuality and chronic illness: A comprehensive approach. New York: Guilford Press.
39. Elrufaie, O.E.F., Bener, A, Abuzeid, M.S.O., & Ali, T.A. (1997). Sexual dysfunction among type II diabetic men: A controlled study. Journal of Psychosomatic Research 43 (6), 605-612.
40. Cooper, A.J. (1988). Sexual dysfunction and cardiovascular disease. Stress Medicine, 4, 273-281.
41. Segraves, R.T. (1988). Drugs and desire. In S.R. Leiblum & R.C. Rosen (Eds.), Sexual desire disorders. New York: Guilford Press.
42. Kaplan, H.I., & Sadock, B.J. (1998). Human sexuality. In H.I. Kaplan., & B.J. Sadock (Eds.), Synopsis of Psychiatry: Behavioral sciences / Clinical psychiatry (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
43. Llisterri, J.L., Vidal, J.V.L., Vicente, J.A., Roca, M.A., Bravo, C.P., Zamorano, M.A.S., & Ferrario, C.M. (2001). Sexual dysfunction in hypertensive patients treated with losartan. American Journal of the Medical Sciences, 321 (5), 336-341.
44. Tengs, T.O., & Osgood, N.D. (2001). The link between smoking and impotence: Two decades of evidence. Preventive Medicine, 32 (6), 447-452.
45. Byrne, D., & Schulte, L. (1990). Personality dispositions as mediators of sexual responses. Annual Review of Research Research, 1, 93-117.
46. Kaplan, H.S. (1979). Disorders of sexual desire. New York: Brunner/Mazel.
47. Geer, J.H., & Fuhr, R. (1976). Cognitive factors in sexual arousal: The role of distraction. Journal of Consulting and Clinical Psychology, 44, 238-243.
48. Sakheim, D.K., Barlow, D.H., Abrahamson, D.J., & Beck, J.G. (1987). Distinguishing between organogenic and psychogenic erectile dysfunction. Behaviour Research and Therapy, 25, 379-390.
49. Zeiss, A.M., & Kasl-Godley, J. (Summer 2001). Sexuality in older adults' relationships. Journal of the American Society on Aging, 25 (2), 18-25.
50. Lustbader, W., & Hooyman, N.R. (1994). Partners as caregivers. In W. Lustbader & N.R. Hooyman (Eds.), Taking care of aging family members: A practical guide. New York: The Free Press.
51. O'Sullivan, K. (1979). Observations on vaginismus in Irish women. Archives of General Psychiatry, 36, 824-826.
52. Kaplan, H.I., & Sadock, B.J. (1998). Human sexuality. In H.I. Kaplan, & B.J. Sadock (Eds.), Synopsis of Psychiatry: Behavioral sciences / Clinical psychiatry (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
53. See Berger, R.M. (1982). Gay and gray: The older homosexual male. Urbana, Ill.: University of Illinois Press.
54. Falk, B., Van Hasselt, V.B., & Hersen, M. (1997). Assessment of posttraumatic stress disorder in older victims of rape. Journal of Clinical Geropsychology, 2, 157-171
55. Gagnon, M., & Hersen, M. (2000). Unresolved childhood sexual abuse and older adults: Later life vulnerabilities. Journal of Clinical Psychology, 6 (3), 187-198.
56. See Goffman, E. (1961). Asylums. New York: Anchor Books/Doubleday. [Detailed analysis of institutional life.]
57. Wiley, D. & Bortz, W.M.II. (1996). Sexuality and ageing-usual and successful. The Journals of Gerontology, 51, 142-150.
58. Schlesinger, B. (1996). The sexless years or sex rediscovered. Journal of Gerontological Social Work, 26 (1/2), 117-131.
59. Poulin, N., & Mishara, B.L. (1994). A comparison of adult attitudes toward their parents' sexuality and their parents' attitudes. Canadian Journal on Aging, 13 (1), 96-103.
60. Walker, B.L., Osgood, N.J., Ephross, P.H., et al. (1998). Developing a training curriculum on elderly sexuality for long term care facility staff. Gerontology & Geriatric Education, 19 (1), 3-20.
    
    
    

Selected bibliography

Bancroft, J. (1989). Human sexuality and its problems (2nd ed.). Edinburgh: Churchill Livingstone.

Berman, J., & Berman, L. (2001). For women only: A revolutionary guide to overcoming sexual dysfunction and reclaiming your sex life. New York: Henry Holt.

Caird, W., & Wincze, J.P. (1977). Sex therapy: A behavioral approach. New York: Harper & Row.

Diokno, A.C., Brown, M.B., & Herzog, A.R. (1990). Sexual function in the elderly. Archives of Internal Medicine, 150, 197-200.

Gagnon, J.H. (1979). Human sexualities. New York: Scott, Foresman.

Geer, J.H., & Fuhr, R. (1976). Cognitive factors in sexual arousal: The role of distraction. Journal of Consulting and Clinical Psychology, 44, 238-243.

Heiman, J.R. & Lopiccolo, J. (1988). Becoming orgasmic: A sexual and personal growth program for women (Rev. ed.). New York: Prentice-Hall.

Kaplan, H.S. (1979). Disorders of sexual desire. New York: Brunner/Mazel. [Beyond simple sexual difficulties, and into the more relevant clinical situations in which individual dynamic and interactional difficulties disrupt sexual functioning.]

Masters, W.H., & Johnson, V.E. (1966). Human sexual response. Boston: Little, Brown

Masters, W.H., & Johnson, V.E. (1970). Human sexual inadequacy. Boston: Little, Brown.

Matthias, R.E., Lubben, J.E., Atchison, K.A., & Schweitzer, S.O. (1997). Sexual activity and satisfaction among very old adults: Results from a community-dwelling medicare population survey. The Gerontologist, 37 (1), 6-14.

O'Sullivan, K. (1979). Observations on vaginismus in Irish women. Archives of General Psychiatry, 36, 824-826.

Renshaw, D. (1996). Sexual disorders. In J. Sadavoy, L.W. Lazarus, L.F. Janik et al. (Eds.), Comprehensive review of geriatric psychiatry. New York: Guilford Press.

Roughan, P.A., Kaiser, F.E., & Morley, J.E. (1993). Sexuality and the older woman. Clinics in Geriatric Medicine, 19 (1), 87-106.

Sakheim, D.K., Barlow, D.H., Abrahamson, D.J., & Beck, J.G. (1987). Distinguishing between organogenic and psychogenic erectile dysfunction. Behaviour Research and Therapy, 25, 379-390.

Thomas, L.E. (1982). Sexuality and aging: Essential vitamin or popcorn? The Gerontologist, 22 (3), 240-243.

Zilbergeld, B. (1992). The new male sexuality. New York: Bantam Books.

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