Sex and the Elderly Man

Hosted by: Mark Pochapin, MD, Weill Medical College of Cornell University, New York

David Kaufman, MD - Columbia University, College of Physicians and Surgeons
Patricia Bloom, MD - Mount Sinai-New York University Medical Center
Dagmar O'Connor, PhD - Columbia University

ABC News, March 16, 2000

MARK POCHAPIN, MD: Hi, welcome to our webcast. I'm Dr. Mark Pochapin, and we're going to talk a little bit about the elderly patient, or actually say the elderly person. When we think about someone elderly, we think about someone who has a lack of function. But today we're going to talk about someone who engages in something that we think more with younger people, such as sexual activity. It's a topic that often doesn't get much attention, but is incredibly important in terms of someone enjoying his life.

With me today are three panelists. Sitting to my left is Dr. David Kaufman. Dr Kaufman is Assistant Professor of Clinical Urology at Columbia University. Welcome. Sitting in the middle is Dr. Patricia Bloom. She's Chief of Geriatric Medicine at St. Luke's/Roosevelt Hospital in New York City. Welcome. Sitting next to Dr. Bloom is Dr. Dagmar O'Connor, who is psychologist, sex therapist, and the first woman sex therapist to be trained by Masters and Johnson here in New York City. Welcome, all.

When we start talking about sex in elderly men, one of the first things that comes to mind is, can elderly men engage in sex? Can they physically do it? Is it healthy for them? Dr. Kaufman?

DAVID KAUFMAN, MD: I think the most important thing I can do today is dispel the myth that as men get older their sexual abilities decrease. On the contrary, that is absolutely not true. There's really no physiologic or anatomic reason why a healthy man who takes good care of himself, and who doesn't have attendant medical problems, shouldn't be able to have a very fulfilling and active sexual life.

MARK POCHAPIN, MD: When men come to a physician who specializes in taking care of older patients, as a geriatrician would, do they come out and say that they're having problems with sexual function? Is it something that needs to be addressed? Or is it something that just should be on the back burner?

PATRICIA BLOOM, MD: I always encourage, I train a lot of young physicians, and I always encourage them as part of the initial assessment, to ask about sexual function. Some patients will bring it up, and it might be more likely that if a patient actually takes himself to see Dr. Kaufman, that's why he's going, and that's the presenting complaint. But with a general doctor, they may bring it up, but they may not. They may be embarrassed about it and be afraid to bring it up. So I think it's very important for the doctor to ask about it, to establish a baseline.

Is the person sexually active? If so, are there any problems? If they're not sexually active, is it because they want to be and they're having a problem, or they don't have a partner? Try to find out what's going on. Speaking about whether having sex is good for men, David's actually absolutely right that elderly men are able to engage in sex. And, in fact, some surveys show that even as much as a quarter of men over the age of 85 or 90 is still sexually active. There are some really fascinating studies about longevity and aging, which suggests that men who are sexually active live longer. In fact, I read one study that said if you have more than 300 orgasms a year, you'll live a long life.

MARK POCHAPIN, MD: That's the best news I've heard all day.

PATRICIA BLOOM, MD: What I think is true is that it's not necessarily true that having sex causes you to live longer, but that people who are healthy enough to be very active sexually are healthy, as David said, don't have other underlying diseases, and in fact that's why they live longer. But there is a correlation between being very sexually active and living a long, healthy life.

MARK POCHAPIN, MD: So there's really no age limit?

PATRICIA BLOOM, MD: No age limit. Well, we know Picasso fathered children in his nineties.

MARK POCHAPIN, MD: It's amazing. Now, Dagmar, you will see a man as a sexual therapy. First of all, how does an elderly man come to a sexual therapist? Are they referred? Do they come on their own volition? And when you meet with them, what is it that you try and accomplish?

DAGMAR O'CONNOR, PhD: They're usually referred either through professionals or through friends, or through my book/video packet that's called "How to Make Love to the Same Person for the Rest of Your Life and Still Love It." It's out there in 15 languages. So there are many referral sources. When somebody is in pain, they start looking around and finding out, and they usually find me one way or the other, because I've been around for 30 years.

What we're trying to ascertain when they come in is, is the problem such that I can help them? Or do they need to go and see David first, who checks them all out physiologically?

MARK POCHAPIN, MD: From a urologic, medical perspective.

DAGMAR O'CONNOR, PhD: Or, to you, if it's a woman. But if it's a psychological problem, I need to take a look at that. Now, I have found that there are personality profiles attached to all sexual dysfunction. A man who comes too quickly or is a premature ejaculator is also somebody who walks fast and talks fast and is never in process, he's always at the endpoint, doing something else. A man who has psychological impotence usually has difficulty expressing his anger. When he gets angry, he withdraws and holds that back. What do I do for him? I tell him to work with his anger; we work with expression of his feelings.

All of these are personality profiles. This is also true for women, and we talk about a woman who doesn't have orgasms. Usually the oldest child, the good girl, the high performer and achiever in the family. So we're talking about the elderly now having personality profiles.

MARK POCHAPIN, MD: It's interesting. Are these things different? Do their personality profiles change from when they're younger and sexually active to when they get older?

DAGMAR O'CONNOR, PhD: Only in this way, that the body changes. I remember seeing a man who was 72-years-old, and he came in to see me, and he said he had difficulty with erections. I said, "How long is your foreplay?" He said "Always 10 minutes." I said "How about 20? Takes a little longer to get aroused when you get older." Next week he came back and he banged on my door, and he was so excited, and he said: "It worked! It was wonderful. Not only that, I came twice in one night, and I haven't done that since I was 14."

PATRICIA BLOOM, MD: That's actually a very, very important point, and I'm sure David can corroborate that. I think if elderly people understood the changes in physiology which make sexual cycles somewhat different, as in men needing to have more physical stimulation in order to achieve erection, and everything is kind of slowed down, right, David?

DAVID KAUFMAN, MD: I think a very significant part of my job when I see somebody who comes to me because of sexual problems, is really reassurance, and is letting them know that what they're experiencing is okay. What's so interesting is that, it's not only the 65-year-olds or the 70-year-olds, but it's the 25-year-olds and the 30-year-olds. We all know that men are supposedly at their sexual peak at age 18, and after, once we go beyond that point, there are changes that happen. Some people are able to go with the tide and acknowledge those changes, but in some cases it causes profound problems. Just hearing an acknowledgment and a reassurance from a physician, makes my job very easy in a tremendous percentage of these patients.

A couple of points I'd like to make. In the past, until recently, we really believed that the vast majority of men with sexual dysfunction were psychologically based. But then as medicine improved and as we understood the etiologies and the physiology of sexual arousal, we have learned that there are very, very many physical and medical problems which, most importantly, can be treated, that cause sexual dysfunction.

Now, having said that, I have never seen a patient with whatever medical problem as an explanation for a sexual dysfunction, that doesn't have a psychological overlay. That's how we work; that's how we're built. You only need to have a bad experience once whether it is caused by vascular disease or neurological disease. But there's no question that, the next time that person is in a similar situation, all he's going to be thinking about is: Is it going to work this time?

I think that even though there are clearcut medical explanations for sexual dysfunction, there is always a psychological overlay. And if that's not addressed concurrently with the medical problem, we've really only done half of our job.

DAGMAR O'CONNOR, PhD: And I think the discussion is: Do we treat the psychological first, or do we treat the physiological first? Because now when Viagra is there, the question is: "All we have to do is get a pill." But, do we address the psychological that. It's a difficult discussion.

PATRICIA BLOOM, MD: In addition to that, I think one of the most interesting things about the availability of Viagra, is all of the men who inundate your office wanting Viagra. I think it's very important, because those men haven't sought medical care in the past, and as David said, many of them do have medical conditions that wouldn't, and it's important to also say that it is important to do the medical workup, not just to give the Viagra. Because they may have diabetes or hypertension or be taking a medication that they just never told their doctor that they became impotent after they started that pill.

DAVID KAUFMAN, MD: Or atherosclerosis, or heart disease. I can't tell you how many men I've diagnosed or I've set on the road to diagnosis for very serious medical conditions, which first presented as sexual dysfunction and impotence. Everything really needs to be looked at.

We've mentioned Viagra without really giving it its full due. Viagra has really revolutionized how physicians take care of men with sexual dysfunction. It's really revolutionized how society sees this problem. Before Viagra, men thought that the only solution to their problem was to have a major surgery, a penile implant put in. But once Viagra hit the pharmacy shelves, people really started facing their problem and coming out of the woodwork and, as Dr. Bloom said, inundating physicians' offices looking for Viagra. So it really has made profound positive changes, I think.

MARK POCHAPIN, MD: It's amazing. Viagra's been out how long, now?

DAVID KAUFMAN, MD: About two years.

MARK POCHAPIN, MD: Isn't that unbelievable, that something that's only been out two years has had such a profound change in the way? I've been asked by patients also, just out of the blue: "By the way, can you also prescribe Viagra for me?" I say, "Whoa, wait a second now. Where's this coming from? We've never discussed this before." I think having some pharmaceutical ability now to intercede and improve someone's sexual function has really changed how people think about sex in an elderly man.

PATRICIA BLOOM, MD: But it can be a problem, because the woman or the partner, may not be ready to resume sex. And Viagra does not work when there is no desire for the partner. I think there can be complications.

DAVID KAUFMAN, MD: And certainly we've all read in the newspaper about social problems that have occurred because of Viagra, where the man suddenly, after not being sexually active for years and years, and they've kind of both, the couple has been in their rut of non-sex. The man suddenly wants to have sexual intercourse, and the woman has gone through physical changes that might preclude her ability to actively participate. It's definitely caused social problems.

It's also initiated physical problems, where men who are not all that active physically would suddenly take the Viagra, find that they had a wonderful erection, want to participate in sex, and really stress their cardiac output more than it's been stressed in 15 years. That's why Viagra has had some amount of bad press over the years of causing myocardial problems, not because of the drug, but because of the activities that that drug allows. That's the important point.

MARK POCHAPIN, MD: Which brings you back to the point that whenever you start prescribing drugs like this, they need to be done under the supervision of a physician, and make sure that a person is capable both physically and emotionally, to deal. And not only that person, but the partner. It's really three-dimensional.

PATRICIA BLOOM, MD: Do you find that men are willing to have that conversation about your relationship, what does your wife expect out of this?


PATRICIA BLOOM, MD: Because I do think that the affect of the woman probably gets ignored, and I think women are afraid. All of a sudden, they're going to be subject to very vigorous sexual intercourse, and they might not be ready for it. Now that the man is ready to go, maybe.

DAVID KAUFMAN, MD: That's the big issue. On the other hand, there are many men who were sent to me by their wives, wanting their husband to become more sexually active, and requesting an evaluation. So it works both ways. And it has to be individualized.

MARK POCHAPIN, MD: But clearly, whatever happens to one is going to affect the other in a couple situation.

DAVID KAUFMAN, MD: That's the way sex works, yeah.

DAGMAR O'CONNOR, PhD: It also brings a couple who have a certain amount of distance, suddenly they cross that distance. And they may not be emotionally ready for it. In my experience, they used it once or twice, and then never used it again.

PATRICIA BLOOM, MD: Viagra. Interesting.

DAGMAR O'CONNOR, PhD: Because it was too scary, too frightening, and too close.

DAVID KAUFMAN, MD: That's why they need you to help them.

MARK POCHAPIN, MD: Is there anything else that a man should be concerned about? We mentioned the health-related problems. Can a man get himself in trouble by taking Viagra or beginning to discuss things that perhaps he thought he shouldn't really engage in, mainly, having sex again?

DAVID KAUFMAN, MD: Do you mean trouble on a psychological?

MARK POCHAPIN, MD: Psychological and a physical basis. Let's start with the psychological basis.

DAGMAR O'CONNOR, PhD: A man who suddenly finds that his wife is not available, and he's now proclaiming to her that he's going to go to other women. Certainly it may cause a lot of problems in the marital relationship. Many men believe that their duty in their sexual relationship is intercourse. There's a large amount of women who are not orgasmic with intercourse, who are not so interested in intercourse, especially older women, who have discomfort. So there becomes a friction in their relationship. And that can be a problem.

PATRICIA BLOOM, MD: I actually heard an interesting twist, also, on the male/female relationship in elderly people, and that is, you have to understand there's a big discrepancy in numbers. And when you get into the far reaches of the age spectrum, when you're talking age 90, there are at least three women for every man. And if you want to talk about sexually active people, there may be four or five women for every man. So you might think, oh, that's nirvana for the man. But I actually heard it expressed by a man saying that there is an affect where, as a man, you might feel like you're being taken as a sex object with all these women.

MARK POCHAPIN, MD: Boy, what a change. You just have to live that long to get to that. Just one last point: There are men who have some underlying cardiac disease who are concerned. Obviously they need some type of medical attention, but can a man with cardiac disease engage in sex at an older age?

PATRICIA BLOOM, MD: One potential big disqualifier to using Viagra is if you are a man with cardiac disease and you take nitroglycerine for heart disease. That's an absolute contraindication to using Viagra, because there have been deaths.

DAVID KAUFMAN, MD: It's not enough to just not be taking nitroglycerine, but there are probably a hundred compounds that have nitroglycerine in them that are used for the treatment of cardiac disease. So you really do need to talk to your physician, let him know exactly what medications you're taking, before you get a prescription for Viagra.

PATRICIA BLOOM, MD: One sort of little helpful guideline I've heard, because there is also the concern after a person's had a heart attack. When can you resume sexual activity? A kind of equivalency that I've heard is, if you can walk up two to four flights of stairs, that's about the same level of physical activity as having intercourse. Of course, I guess, depending on the nature of the intercourse. But if you can do that without having chest pain, then probably you'll be okay.

And then, of course, you should talk about potential modifications. I remember one patient of mine who had angina, and he would be so embarrassed that I kept trying to encourage him to use a different position. Let your partner do the work. You be on the bottom. And he'd say "Oh, Dr. Bloom!" So you can talk about different positions and which expend more energy.

MARK POCHAPIN, MD: Again, the most important thing seems to be communication with your physician, with your partner, and understanding the physiologic and psychologic basis of this.

Thank you all very much. This has really been a very interesting conversation. We appreciate our audience for joining us today. Hopefully we've all learned that, as men get older, things may even seem to get better, if they can stay sexually active. Which, it sounds like, with new drugs and appropriate medical care, they can.

I'm Dr. Mark Pochapin, and thank you for joining us.