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…

What Do You Think? Doctors and Shopping

I’d like to solicit your opinion.

As you know, (or… maybe you don’t) MiddlesexMD has an online store in which we sell all kinds of products geared toward the sexual needs and pleasures of older women—“for midlife women who want to enjoy sexuality for life,” as we say. And some products just for fun.

As I’ve explained before, I created this store for a generation of women who need more sexual stimulation, lubrication, and support, but who probably aren’t going to check out their local sex shop (assuming there is one) and who probably aren’t savvy or experienced shoppers when it comes to choosing items like vibrators or warming oils.

So my team and I did the shopping (when was the last time you went to an “adult” trade show?), testing, and selecting of products we thought would be helpful and safe for midlife women.

It wasn’t easy, let me tell you, but I’m proud of our selection, and I’m confident about the quality of their design and construction and the safety of their materials. Full disclosure: MiddlesexMD is a business, so there is some profit involved.

So what’s the problem?

Because I have this dual role—as a practicing physician and as MiddlesexMD, other health care providers ask my advice about product sales. I know that the doctor-patient relationship is a tender thing, and it’s based on trust. My patients trust me to use my skills on their behalf. They don’t want my commitment to their health and well-being diluted or divided by self-interest. Nor do I.

When doctors sell products, conflict of interest is always lurking. Can doctors be objective when they stand to make money by recommending this vitamin or that weight-loss aid? And wouldn’t patients feel some pressure to buy the product to please the doctor? Does the presence of the product in a doctor’s office imply that the doctor endorses it?

The fact that some doctors derive a significant portion of their income from selling these products in their offices reinforces that appearance of ethical shadow-boxing. A few “celebrity” doctors have become virtual mouthpieces for certain product lines, which often lack research as to their efficacy or even safety.

As you can imagine, the issue has engendered passionate discussion both pro and con within medical circles, and professional medical organization have yet to issue any guidance regarding the practice.

I can honestly say that my primary motivation for selling products that I’ve tested and sometimes use myself is to provide a tasteful, private, safe opportunity for women to buy intimate items that will help keep them sexually active and comfortable and that they’d have a hard time finding otherwise. I set prices comparable to other retail options.

I practiced medicine for years before bringing products into my office. My relationships with patients were well-established. And I’ve seen first-hand that women are more likely to follow through when I can show them what lubricants feel like or how a vibrator functions. When my patients can walk out with products they’re ready to use, rather than with one more research project for their to-do lists—well, I think that’s useful and convenient. I’m not sure I would still have an electric toothbrush if my dentist didn’t offer them for sale.

So I’d like to think I’m offering a valuable service to my patients, but can I truly be objective when I have something, however modest, to gain? Do my patients feel subtly obligated? Do I compromise my professional credibility?

What do you think? Service or self-serving? I’d really like to know.

Three Sex-Killing Bogeymen

The stroller is in mothballs, along with the Little League jersey and the Cub Scouts uniform. Just when the kids can brush their own teeth and maybe drive themselves to hockey practice, just when you thought the never-ending physical demands of raising children might slack off. Just when you thought you and your partner might finally, finally get some time alone, you realize that:
  • Your mom isn’t doing well and needs more support, probably from (who else?) you!
  • You’ve unmistakably entered “the change” and your ability to roll with the punches isn’t rolling anymore.
  • Instead of becoming more independent, your teenaged children have only become more mobile, not necessarily more trustworthy; they are also acutely aware of what goes on behind closed doors. Your closed door, in particular. Plus, they stay up until all hours, while you are practically going to bed with the sun.
  • Or (alternate scenario) your 20-something was just sucked into the economic downdraft and lost his job. He’s moving back until he finds another.
  • Neither you nor your partner is getting any younger, to which your rickety knees, complaining back, and unsteady blood pressure can attest.

Sex? Can you spell that?

According to the North American Menopause Society (NAMS), fatigue, stress, and lack of privacy are three common bogeymen of midlife sex. Maybe you once thought you’d have everything figured out by now. As it turns out, the reality on the ground looks much different.

You belong to the sandwich generation, remember? You care for aging parents and your own growing children—who stay up late and are acutely aware of sexual innuendo. The boomerang kid lands at your doorstep. And just when your own career is at its most demanding, you’re tossing at night from insomnia and hot flashes and don’t perform well at the morning meeting with (choose one) the partners, the customer, the staff.

While you can’t magically fix everything at once—stress and fatigue won’t dissipate overnight, and you won’t be able to leap passionately into bed tonight with a rose clamped between your teeth—yet, you might keep in mind the airline attendant’s advice: Put the oxygen mask on yourself first. Because if you can’t breathe, what earthly good are you to anyone else?

You can’t do anything about your teenagers’ sensitivity or your parents’ fragility or your menopausal discomforts, but you can pay attention to your physical and psychological health and to the partner who, God willing, will still be around when the other demands have eased.

Try these stress-busters:

  • Eat healthfully. You’ve heard this before, but the wisdom of the ages bears repeating. Your body simply won’t keep up with all the physical demands if you’re overeating or consuming the bad stuff. Think fruits and veggies, not fries and burgers. Think whole grains, not white rice and Wonder bread. Avoid refined sugars, fats, and processed foods. Avoid alcohol. Cut back on caffeine, which, according to NAMS, elevates levels of cortisol, the “stress hormone.”
  • Meditate.  Guided imagery or mindfulness meditations are simple and surprisingly effective techniques to help you relax and check in with yourself emotionally. They’re refreshing to the spirit and the closest thing to magic at relieving stress. For a superb two-fer—a stress-relieving meditation and a gentle workout, try yoga.
  • Exercise. If you don’t stay active, your body simply won’t work well. Exercise is the third leg of the stool to lowering stress, improving your mood, and keeping joints, organs, and muscles functional. It doesn’t have to be strenuous, but it does need to be regular—30 minute sessions four to five times a week. If you can get outside, all the better.
Now for the fun stuff:
  • Relax and do something nice for yourself. Take a bath. Get a massage. Get a makeover. Go out with friends.
  • Laugh. It makes you prettier and it relieves stress. All the experts say so.
  • Create a boudoir. If your kids are going to smirk and giggle anyway, give them something to be really embarrassed about. Make your bedroom a sexy little place just for you and your partner. Your kids will never again enter without knocking.
  • Play with toys. Sex will take longer and may require some props as you both grow older. But according to several studies, you’ll enjoy it more. So what are you waiting for? Check out our website, both to educate yourself and for our selection of sex enhancing toys.
  • Take your time. Maybe you’ve noticed that most of these suggestions require time, which may seem as scarce as snow in Tahiti. But that’s just the point, isn’t it? You have more demands than ever on your time and energy. But if you don’t fill the gas tank, you’ll be running on empty.

Couples at Midlife

Until recently, no one has given much thought to the sex life and relationship satisfaction of middle-aged couples in long-term relationships. You know, ordinary people. So no one knows what keeps long-term couples happy together and happy in bed together.

Recently, however, the Kinsey Institute conducted an international survey of 1,000 couples from the U.S., Germany, Spain, Brazil, and Japan. The median age for men was 55 and for women, 52. The average couple in the study had been together for 25 years. Sound familiar?

In this first study of its kind exploring the “sexual and relationship parameters of middle-aged and older couples in committed relationships,” the Kinsey Institute wanted to identify qualities that contributed to the sexual satisfaction and relational happiness of these couples.

Some of the researchers’ findings were unremarkable, but others surprised even the researchers.

In this survey, respondents and their spouses answered questions about their health, sexual history, how often they kissed and cuddled, how often they had sex, and how often they felt arousal or desire, along with a bunch of other intimate details about their lives and relationships. The researchers focused on physical intimacy, sexual functioning, and how long the couple had been together as qualities that would be particularly predictive of sexual and relationship satisfaction.

They hypothesized that there would be few differences between men and women, but that women would tend to have less satisfying sexual relationships and that physical intimacy would be more important to them.

They weren’t as accurate as one might think.

First, duration—the length of time couples were together—did indeed contribute significantly to relationship satisfaction for both men and women, but in different ways. For men the connection between relationship happiness and its duration was linear—the longer the relationship, the greater the satisfaction.

For women, on the other hand, relationship satisfaction decreased until year 15, and then it steadily increased from year 20 on. Researchers hypothesize that this effect was due to the stressors of the childbearing years, and that once those years are past, “this change, along with the freedom from reproductive worries, may facilitate greater levels of sexual satisfaction…”

A surprising outcome was that men who cuddled and kissed more were also happier in their relationships. Physical intimacy was a more important predictor of relational satisfaction for men than for women. No such straightforward effect was found for women. Duration of the relationship and sexual functioning was more closely linked to relationship satisfaction than was all that kissing and cuddling.

This effect came as a surprise. “The degree to which physical intimacy (that was not necessarily sexual) was rated as important to men’s but not women’s relationship happiness was striking,” write the researchers, “suggesting a need for reconsideration of the role of physical affection and its meanings for each gender in longer term relationships.”

However, women were happier with their sex lives when the relationship included lots of physical intimacy. So although physical intimacy was linked to sexual satisfaction for women, it wasn’t so closely linked to relationship satisfaction, which suggested to the researchers that the two qualities operate somewhat independently.

For example, people who were satisfied with their sexual relationships also tended to be satisfied with their relationship (and this tendency was particularly marked in women who had been married over 30 years), but conversely, happiness in the relationship didn’t necessarily translate to sexual satisfaction.

Sexual functioning was important to both genders, but it was actually more important to women. Women who reported high levels of sexual functioning were significantly more satisfied with both the sex and with their relationships.

Overall, the report concludes, “women reported significantly more sexual satisfaction than men and men more relationship happiness than women, contrary to our hypothesis.”

So, ladies, it ain’t over til it’s over for any of us. Sex remains more important than ever as we get older, and it significantly impacts the quality of our lives. Sexual satisfaction contributes to the stability of our relationships, and if we can remain physically intimate and sexually active, we’re more likely to be happy with our sexual relationships as well.

These results have important repercussions for the choices we make at this time of life when we can no longer take our sexual apparatus, or our health, for granted. All our physical parts just take more attention and maintenance, but keeping our bodies and our sexual organs in good working order is absolutely critical to our quality of life—and to the quality of our relationships. And that’s the takeaway from the Kinsey research.

Alive! Alive-O!

A story is necessary to bring about the appropriate emotion...

When I was in my early 40s, I decided I needed to run a big race. Not so much a long race, but a big one, with crowds and a chip on my shoe and a finish line and a medal. A real race. At the time I was pretty heavy, but working on getting leaner, and putting a big race out in front of me seemed a good goal. Something to look forward to, and a kind of capstone to all the hard work of losing weight and getting fit.

As it happened, the perfect race would be run in Dublin at a time when I planned to be in Ireland anyway, riding in my husband’s bags as he went there to teach for one lovely month of May.

This race is an annual 8K, dubbed a mini-marathon, run entirely by women, and doubles as one of the biggest fund-raising events in Ireland every year. That day 40,000 women gathered in the center of the city to await the starting gun. Tradition dictates that  all these women together sing the first verse of the old Irish folk song, Molly Malone, just before the race starts...

In Dublin’s fair city
Where the girls are all pretty
I first set my eyes on Miss Molly Malone.
As she wheeled her wheel barrow,
Through streets broad and narrow,
Crying “Cockles! And Mussels! Alive! Alive-O!”
Alive! Alive-O! Alive! Alive-O!
Crying “Cockles! And Mussels! Alive! Alive-O”

This makes absolutely every woman in the field begin their run with tears streaming down their faces, and feeling the ghost of Molly in their hearts, and feeling very much alive. I haven’t quite felt so glad and proud to be alive and kicking as I was that day.

Until today. Because tomorrow, goes live. We’re all thrilled and a little terrified, waiting here, at the starting line. This blog has been a bit quiet for the past month as we’ve all been hurling ourselves into our final wind-sprints. This is an amazing group of experienced, wise, and funny midlife women who have worked hard for a year now to pull off Dr. Barb DePree’s dream of a smart, informative, trustworthy place for women in menopause to explore and sustain their sexuality for life.

And it has been a dream project. Important. Fascinating. We have learned so much, and look forward to learning so much more. Learning from you, for you, and making all the necessary connections that women our age need to keep feeling Alive! Alive-O!

Please take the time to take a peek soon, and tell us what you think!