February 28, 2014

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Aging—and Loving—in America

I don’t always catch AARP The Magazine, I suspect because I’m still adjusting to thinking of myself as part of their demographic. But the most recent issue contained an article I’m glad I saw: “You’re Old, I’m Not,” a report on an AARP survey on “Aging in America.”

Among the findings are a few you’ll accept as common wisdom: People in their 40s define “old” as younger (63) than people in their 70s (75). As we grow older, we find that the process is “easier than I thought,” that we’re not held back from doing what we want to do. Older people appreciate old-folks humor more than younger folks do.

One section of the results, though, sparked my interest in a different way. There’s a difference by gender in agreement with this statement: “I know I’ll enjoy sex no matter how old I am.” Seventy-one percent of men agreed; only 51 percent of women did. Gender mattered much more than age: There’s only a 7-point difference between people in their 40s (66 percent) and people in their 70s, 59 percent of whom still expect to enjoy sex.

Given my line of work, I take that difference by gender as something as a battle cry. I certainly don’t want women to be like menvive la différence! But I take it as a personal, professional, and generational challenge to see more women look forward to enjoying sex!

I doubt that AARP was able to delve into the thinking behind people’s responses to that question. My guesses about why women are less optimistic than men are based on my years as a menopause care provider, not on AARP’s data. But here are my theories:

First, we’re young at understanding menopause. The average age for menopause is now 50; until 1900, few women lived past that age. We’re living longer now, and have much more experience with menopause, but we have no deep cultural expectation of conversation about it.

And that leads to the second factor: In the absence of good information, the worst-case scenario tends to take over our imaginations. Have you noticed that talk about child birth and root canals nearly always leads to the sharing of horror stories—the labor that lasted four days, the excruciatingly painful dental experience? Even though those stories are the exception, not the rule? I’ve seen the same thing happen with women talking about menopause, and the women who hear those stories are more willing to accept limitations and less empowered to take control of their own sex lives!

There’s one more factor, too: We as women start to receive messages that sex and older don’t compute. For some reason, “sexy woman” conjures a young woman in our media and culture—and, for some reason, we’re susceptible to that suggestion!

I don’t know when AARP will conduct this survey again. But when they do, my hope is that women agree just as often as men that “I’ll enjoy sex no matter how old I am.” Because we can, when we take the time to understand what’s happening as our bodies change. And we want to, when we recognize what sex means to our health, our well-being, and our relationships—and all the ways those intertwine.

And, okay. Because we women can be a little bit competitive, too.

Shhh No More!

We had a focus group a couple of weeks ago, a gathering of women to check in on what’s on women’s minds. One of the questions we asked was to whom women talked about sex—beyond their partners—and about any sexual health questions they might have. The answers were just as varied as I thought they might be. One woman said she’d talk to a stranger on an airplane—someone to whom she could say, “See you never!” Another woman has a group of long-term friends who she says frequently talk about any part of life—including sex.

I remember sex as a subject of great interest and fascination when I was very young—whispers, conjectures, a lot of mis-information and tall tales. By high school, we knew more, the better informed among us bringing along the uninformed. In college, we received a great deal more detail as data from actual, rather than fictional, experimentation became more commonplace.

It may be marriage that closes our mouths. We may be willing to share exploits or guess at sex before we choose our mates, but once we do, the walls of privacy go up, and silence rules our sexual lives. Or maybe we’re susceptible to the cultural messages that suggest that older women plus sex equals nonstarter. Maybe we’re embarrassed, as we approach and pass into menopause, that we’ve got “symptoms”; we don’t want to become Great Aunt Tessie, who shared her upper-GI details at every family gathering.

I buy the privacy reason, the loyalty to one’s partner. But I reject the cultural messages and the embarrassment. We should allow nothing to get in the way of our opportunities to continue to learn and explore, and to find reliable sources of information and aid when things aren’t working. Because, let’s face it, most of us weren’t trained in sexual techniques—or even anatomy. We need information as we grow and change sexually, and most particularly during menopause, when our bodies, while still miraculous and powerful, are less predictable and consistent.

So, please. Talk. As a reserved Midwesterner, I’m not sure I recommend raising the topic with your fellow passengers on airplanes—but far be it from me to discourage you. Talk to your partner about how your experience is changing. Talk to your friends to compare notes—and recommendations for health care practitioners or websites or books you find helpful. Talk to your health care provider, and be sure s/he is listening. Join us on Facebook or Twitter. Use our Ask Dr. Barb button, front and center on our website; you’ll get a private, personal answer and may inspire a future blog post Q&A.

View from the Trenches

Dr. Susan Kellogg Spadt on Sex and Aging

Have I mentioned recently what a great team of medical advisors is associated with MiddlesexMD? We regularly draw from the wisdom and experience of leaders in the field of aging and sexuality. In the next two posts, we’ll hear from Dr. Susan Kellogg, who is not only one of our esteemed advisors, but who also co-founded and directs the Pelvic and Sexual Health Institute in Philadelphia. Read on as Dr. Susan shares with us some of the barriers to sexuality for older women. And thanks, Susan!

In my practice I regularly see women in their 60s and 70s. What often impresses me is how unique each is in her experience of sexuality.

Some still like sex and remain sexually active, while others just aren’t interested—even if they have a functional partner.

Of course, there’s been a lot of research, mostly on the age-related changes men experience. I think this is because male sexuality is more straightforward. With women, as has been said elsewhere on MiddlesexMD, it’s complicated.

So, let’s look at some of the impediments to sexuality for women as they age.

Internalized ageism. We absorb cultural messages all our lives. They bombard us from the media, from religion, maybe from the region we live in or the ethnic group we belong to. The messages can be subtle (“Good girls don’t…”) or they can be in-your-face (“You’ve come a long way, Baby.”)

While the messages have shifted over the years, some are inconsistent and some remain the same. For example, one consistent message is that “real” men remain sexually active as they age. (Which, I’m thinking, can be pretty tough on men, too.) For example, an older man’s ability to attract (and, presumably, to satisfy) the “trophy” wife is a status symbol synonymous with wealth, virility, and power. The messages are mixed for older women. It’s desirable to be a “cougar” in your 40s and 50s, but the ground shifts subtly after that. Despite the sexual older woman portrayed by the Golden Girls, or by Diane Keaton in Something’s Gotta Give, or Meryl Streep in Mamma Mia, the word on the street is that we older women ought to settle gracefully into our roles as the sexless Grandma. A foxy granny just doesn’t play well.

We, in turn, can be very sensitive to these cultural expectations, and we can allow them to define us. We can internalize them.

In fact, research suggests that gay men and heterosexual women are highly susceptible to internalizing cultural messages that equate aging with loss of interest in sex.

When we implicitly assent to the message that we’re old and therefore no longer sexually attractive or viable, it can affect our self-esteem and our experience of sex and intimacy. The message is false, and believing it is a shame.

Sexual scripts from families-of-origin. Just like societal messages, we absorb beliefs and assumptions about sex from our families. They can be deeply imprinted on our young minds, and they don’t have to be clear or verbalized. In fact, our families are often the first place we learned about sex.

Did our parents smooch and cuddle or were they cold and distant? Did sex seem natural and loving or was it something shameful and dirty? Did the sex stop at some point? Did they move to separate beds or separate bedrooms? Did this seem to be expected at a certain age?

Women commonly internalize direct and indirect messages about aging and sexuality from family members. Usually, we’re not even aware of it.

Low self esteem. It’s hard enough to maintain a strong sense of self-worth in this world without the added insult of getting old in a culture that absolutely idolizes youth and beauty.

We may have survived the adolescent jungle and our family of origin with, I hope, few scars. Many of us have struggled with self-esteem, and that struggle has only changed, not ended.

Now we’re hit with an entirely new challenge: how to maintain our confidence and positive self-image as we grow old in a culture that seems to have no use for us simply because we’re not young.

It’s unfair and it’s insulting, and it takes a strong sense of self to stand against that bias.

Unfortunately, for some women, feelings of low self-worth become an impediment to sex. I think this is why some women complain about feeling unattractive and losing desire. It’s hard to feel sexy when you feel dowdy and useless.

One client even said that when she saw her sagging breasts in the mirror she felt that she did not “deserve to have sex.”

The truth is, of course, that beauty has a lot more to do with confidence and creativity than with perfectly taut skin. Cover up the mirrors. Be proud of your wrinkles! You’ve earned them. To be continued…

Sex and His Self-Esteem

Ladies, sometimes we are just too full of ourselves.

Yeah, it’s tough growing older in a society that adulates youth. It’s especially distracting in bed: Does he see the cellulite on my thighs? When I’m on top, my belly sags like a pregnant dog, so let’s stick to the missionary position. While we’re at it, nothing stronger than a candle. One candle.

Of course, our secret vulnerability is that we yearn, in the secret recesses of our still-adolescent souls, to be desired. To have the person we love (or maybe someone who looks like George Clooney) think we are the most beautiful creature he’s ever seen. In such a way that we know it’s true.

And, of course, as we discussed before, everything in our culture, in our psyche, and maybe even from our family of origin rewards youth, beauty, and thinness. And we are not those things any more.

But what about men?

Aren’t they unscathed by cultural expectations about sex and intimacy? They created them, didn’t they? And they don’t have to be in the mood. They don’t have the same, um, unpredictabilities when it comes to getting it off in bed. Things are just more straightforward for guys.

Not really.

I’ve been doing some reading lately, and it’s given me a different perspective on Mars. The cultural messages and expectations they absorb almost from the cradle are equally potent and can be equally unrealistic and even damaging. And part of the message is that they aren’t supposed to talk about it. No whining, no complaints, just be a man. Get it up and get her on.

Consider this observation from a researcher who has interviewed men (and even more women) for many years: “… From the time boys are from eight to ten years old, they learn that initiating sex is their responsibility, and that sexual rejection soon becomes the hallmark of masculine shame." She heard this from a man she interviewed:

"Even in my own life, when my wife isn’t interested, I still have to battle feelings of shame. It doesn’t matter if I intellectually understand why she’s not in the mood. I’m vulnerable, and it’s very difficult.” (From Daring Greatly by Brené Brown).

I encounter this sentiment repeatedly. Men are vulnerable too. Because they usually initiate, they can be rejected. And they’re “responsible,” not only for their own orgasm, but in some way for ours. After all, if they were slower or faster or lasted longer or were more skilled….

There’s a reason for performance anxiety in men. A lot is riding on that “performance.” They don’t articulate it, not even to themselves, but their self-worth is connected to “performing” well. And if we don’t get off, or, God forbid, if they don’t, the result is shame.

“A guy can’t get through the day without seeing an ad for an erectile stimulant, getting spam about some sort of penis enlargement pill, or hearing sexual tall tales from the guys in the locker-room,” says Ian Kerner, author of She Comes First. “We live in an age where a lot of guys feel like they have to make love like porn stars, and with all the cultural reinforcement, it’s hard to believe otherwise.”

When you think about it, ladies, who are the male role models put before our men and boys? Wouldn’t the Disney Princess counterpart for boys look something like GI Joe or the Terminator? And for men, according this Esquire list, it’s George Clooney (who “eats class for breakfast”) and Liam Neeson. (Actually, the list is incredibly thoughtful and diverse. Check it out.)

But the point is that social pressure on boys to be “men,” and how we define “manly” is every bit as intense and constricting as is the pressure on us to be young, beautiful, and thin. And performance in bed is absolutely integral to the definition of being manly.

“Sexual prowess is the Holy Grail of manhood,” writes Scott Alden. “More than success, more than athleticism, more than witty banter—if we’re not a killer in the sack, we’ve failed as men.”

Ouch.

But what is really sweet, actually, and vulnerable and heartbreaking is that the thing your man wants most—even if it’s buried deep inside under years of habitual behavior in bed and out—the thing your man want most, is to turn you on and to know that he did it.

Truth. Nothing is sexier to a man than to turn on the woman he loves.

“For men, there’s nothing sexier in a woman than awakened desire,” writes Alden. “We also have a deep-seated need to keep our mate committed to us, and pleasing her better than anyone else in the history of sex has ever pleased anyone would be a good way for us to do that.”

All of us—men and women—are stereotyped in unhelpful ways by our time and culture. We’d probably have a lot more fun if we understood the forces that form us and viewed each other with a little more compassion.

An Hysterical History

As we saw in the last post, vibrators were developed by doctors in the late 1800s to replace the “pelvic finger massage” they routinely administered to female patients. The massage was intended to relieve symptoms of “hysteria” or “neurasthenia,” such as anxiety, sleeplessness, and general malaise. Done successfully, it induced a “hysterical paroxysm,” which offered temporary relief to patients. By some estimates, over 75 percent of women suffered from these symptoms.

By the early 1900s, small electric vibrators had a comfy niche in middle-class homes right on the shelf between the toaster and the electric iron. At the time, they were perceived as medical devices that had nothing to do with sex.

The porn industry, however, was not so easily deluded. In the late 1920s, early porn films embraced the gadget for its own version of “doctor.” In this context, the “hysterical paroxysm” looked unmistakably like (gasp!) an orgasm. Once that connection was made, the veneer of the vibrator as a nonsexual treatment for a medical condition became uncomfortably hard to sustain, and the vibrator quietly disappeared from respectable society and doctors’ offices.

It became so utterly invisible, in fact, that in the 1970s only 1 percent of women had ever used one, according to the Hite Report, a famous study of female sexuality. “This was perhaps unsurprising, given that most vibrators by then were modeled on a very male notion of what a woman would want–a supersized phallus–replicating, in other words, the very anatomy whose shortcomings had precipitated the invention in the first place,” writes Decca Aitkenhead, in the Guardian.

At the heart of the matter was that:

  • At the time, women (of a certain social class) were simultaneously idealized and condescended to. They weren’t supposed to be sexual, to want sex, or to enjoy it.
  • The only “real” sex was penis-in-vagina penetration until the male reached orgasm.
  • If this didn’t satisfy a woman, the fault was hers. She was either defective, frigid, or “out of sorts” (in Victorian parlance).

Rachel Maines, author of The Technology of the Orgasm, the seminal work tracing the history of the vibrator, commented in an article in the Daily Beast, “In effect, doctors inherited the job of producing orgasm in women because it was a job nobody else wanted. The vibrator inherited the job when they got tired of it, too.”

That many women were not completely (or at all) satisfied by ordinary coitus was a source of confusion, frustration, and threat to some men. According to the Hite Report, most women can reach clitoral orgasm through masturbation. But the idea of women masturbating was also extremely threatening.

“I have read debates between doctors over whether women should be allowed to ride bicycles or whether the pleasure they might induce from the seat made it an unacceptable moral hazard,” writes Erik Loomis in “The Strange, Fascinating History of the Vibrator.”

Lest you think that we’ve evolved beyond these repressive and delusional ideas and that female sexuality is more acceptable today, think of the recent diatribe against a college student who spoke in favor of requiring health insurers to provide contraception. Or the statements alluding to “legitimate rape,” or the suggestion that a woman can’t get pregnant because her body “will shut the whole thing down.”

Have we really come all that far, Baby?

In any case, the discredited vibrator slunk back into view in the 1960s, first as a kinky sex toy and then as a symbol of women’s sexual liberation by feminists.

In a major national study of sexual behavior conducted in 2009, of over 2,000 women surveyed, 52.5 said they had used a vibrator.

If nothing else, the peculiar story of the vibrator should help us recognize how strongly we are influenced by cultural messages. A vibrator is not a medical device nor is it some unsavory symbol of sexual deficiency. For those of us who need extra stimulation to keep our sexual parts lubricated and functional, it’s just one important tool.

Where Angels Fear to Tread

Sex and religion aren’t often mentioned in the same breath. One is fleshly; the other spiritual, right? Like oil and water.

Yet, both are integral to our person and to our psyche. Both faith and sexuality are deep expressions of who we are. We can’t chuck our sexuality at the door of the church or temple or synagogue; nor can we drop whatever we believe about God at the door of the bedroom.

So I was interested to read about a recent survey conducted by psychologist Darrel Ray, who compared the behavior and feeling of nonbelievers (agnostics and atheists) to those of believers (mostly of Christian persuasions). In a nutshell, he found that both groups behave similarly. Both became sexually active at about the same age, have similar levels of sexual activity, do the same things in the bedroom. They even pursue affairs at similar levels. The significant difference was that the believers tended to feel more guilty. This was particularly pronounced in more fundamental denominations: Mormons, Jehovah’s Witnesses, Seventh Day Adventists, Pentecostals, and Baptists. But mainline Protestants and Catholics experienced higher levels of guilt, too, than atheists or agnostics. Not crippling, but noticeable.

Leaving aside for a moment serious questions about Dr. Ray’s motive and methodology (he calls religion a disease and himself a “recovering religionist”), his report raises some interesting questions. Do people who believe in God feel guilty about sex? Are certain acts, masturbation or oral sex, for example, more troubling or guilt-provoking? If so, why would this be? Does guilt derive from actual church teaching or from cultural conditioning or from something misunderstood or misapplied in childhood?

Even the religious institutions themselves struggle to honestly incorporate sex in a faith context. Yes, sex, in the context of a loving, uncoerced relationship, is a beautiful, God-given gift. Just read the Biblical Songs of Songs. However, as it’s practiced on the ground, the message isn’t all that clear, and even some church leaders admit as much.

“In the context of Catholic teaching, I would think it safe to say that the connection [between faith and sexuality] is contorted, controverted, and often confusing,” says Dr. Michael Higgins, vice-president of Mission and Catholic identity at Sacred Heart University in Fairfield, Connecticut.

“If we could only transcend the ‘forbidden fruit’ mindset, perhaps religion could evolve into a much healthier sexual ethic,” said Rabbi Howard Voss-Altman, of the Reformed Jewish tradition.

Dr. Sheema Khan, a practicing Muslim, said that “…sexuality forms part and parcel of [Muslim] spirituality. There are even prayers prior to sexual intercourse, and… foreplay is encouraged (as part of religious teachings).” But she also condemned the Muslim preoccupation with the “purity of women,” which could result in the ritual killing of a woman suspected of having sex outside of marriage.

So it would seem that if we aren’t sure how to feel about sex or some sexual behaviors, or if some indefinite guilt is associated with sex, we aren’t alone. Our religious institutions are grappling with the same issues.

But isn’t this the nature of life—to honestly articulate and wrestle with our inconsistencies? And in the end, to become more mature and integrated?

I remember the advice a wise old pastor gave my mother when she was trying to reconcile church teaching with the expression of sex in her marriage. “I don’t think that anything a loving couple does in the bedroom to give each other pleasure can possibly be sinful,” said this man of God. Amen to that.