Sex and Relationships in Later Life: Older Adults’ Experiences and Perceptions of Sexual Changes

ABSTRACT

The aim of this study was to explore the sexual lives of older adults in the UK to elucidate their experiences of sexual changes and problems, and the role of intimacy and interpersonal support in coping with these changes. We conducted in-depth semi-structured interviews with 31 participants (aged 66–92, mean = 74, 16 women and 15 men), analyzed using reflexive thematic analysis. Our analysis generated three themes: Sexual Changes are “Natural,” Sex is the Icing on the Cake, and Maintaining Sexual Connection and Relationship Satisfaction. The participants often rationalized and accepted sexual changes and problems as part of the natural aging process, or as a consequence of other age-related health issues. Sexual activity was seen by many as the “icing on the cake” of a satisfying romantic relationship, built on strong foundations of intimacy, connection, and companionship. Relationship satisfaction and sexual wellbeing can be maintained despite changes to sexual function by retaining a sexual connection through shared experiences, emotional closeness, and support. The findings have important implications for researchers and health providers, and suggest that adopting an “affirmative older age” perspective would be useful for not only future research but also when providing support for older adults with sexual difficulties.

Significant social and cultural changes regarding sexuality have occurred over the past 60 years, such as attitudes toward extra-marital sex and same-sex relationships, during which the current generations of older adults in Western societies have developed and lived their sexual lives (Syme, 2014; Træen et al., 2016). When they were children (or for the “oldest old” generation, up until they were young adults) sexual activity and expression were taboo, particularly outside of the context of marriage and heterosexual norms. Later, they lived through significant changes – not only to these social mores, but to human rights policies aiming to protect people from inequalities and prejudice based on sexual orientation, gender, and race (Hinchliff & Barrett, 2018a). Older adults today are the first to have experienced the sexual freedoms brought about by these social movements, while they are also in the unique position of having experienced the tension between the constructs of sex for reproduction and sex as self-expression.

However, our understandings of sex and sexuality remained within the biomedical sphere until relatively recently. Rather than simply a matter of reproduction, sex started to become viewed as a medical issue, particularly when increasing life expectancy meant the potential for extending our sexual lives. A common barrier to sexual expression in later life is problems with sexual function, such as vaginal dryness, lack of desire, arousal, and/or orgasm, and pain during sex for women and difficulties with getting or maintaining an erection, anorgasmia, premature ejaculation, and genital pain for men (Christensen et al., 2011; King et al., 2007; Latini et al., 2006; Laumann & Waite, 2008; Lindau et al., 2007). This awareness contributed to the advent of “sexuopharmaceuticals” (medications to enhance sexual function and performance; Potts & Tiefer, 2006) in the late 1990s, including Viagra. Thus, links between sexual activity and health and wellbeing in later life began to gain traction. A flurry of empirical research sought to establish the prevalence of sexual frequency in later life and its relationship with health and wellbeing factors, such as chronic conditions and relationship status (DeLamater & Moorman, 2007; Kontula, 2009; Laumann & Waite, 2008; Lindau & Gavrilova, 2010). As such, retaining sexual function and frequency in later life soon came to be viewed as a marker of “successful aging” (Marshall, 2011; Vares, 2009), where remaining sexually active was framed as a personal responsibility (Katz, 2001). It has been argued that such thinking has led to the creation of a new stereotype: the “sexy oldie” (Gott, 2005), which refers to presentations of vitality and sexual activity in later life, and the stigmatization of sexual inactivity (Hinchliff & Gott, 2016). The tension between this newer stereotype and the more traditional mold of the non-sexual older adult is problematic for those who do not – or cannot – conform to the “sexy oldie” ideal, as those who do not conform risk presenting themselves as “in decline” and uncaring about their health and wellbeing (Hurd Clarke, 2010; Katz, 2001).

More recently, our understanding of sexual problems has begun to broaden. The third iteration of the nationally representative British National Survey of Sexual Attitudes and Lifestyles (NATSAL-3) explored personal sexual function domains, but also broadened the scope by enquiring into sexual function in a relationship context, and individuals’ appraisals of their sex life (Mitchell et al., 2013). NATSAL-3 found that 27% of men and 21% of women aged over 65 were classified as experiencing low sexual functioning, and for women, a lack of interest in sex and vaginal dryness were the most commonly reported sexual problems (Mitchell et al., 2013). For men, 30% of men over 65 experienced erection problems, with 54% of older men experiencing one or more sexual problem lasting 3 months or more (Mitchell et al., 2013). Comparative findings for older men and women have been reported from wider European and US contexts (Graham et al., 2020; Hald et al., 2019; Laumann & Waite, 2008; Lindau et al., 2007). However, a notable difference is that NATSAL-3 found much lower rates of orgasmic difficulty than these other surveys; for example, 14% of women over 65 in NATSAL-3 vs. 50% in the Graham et al. study (Graham et al., 2020). It is important to note that these surveys focused on heterosexual men and women. Mitchell et al. (2013) found reporting a same-sex partner in the past 5 years was associated with low sexual functioning, though the survey did not provide insight into why this may have been the case. One qualitative study, however, indicated that while gay men may report similar sexual difficulties to heterosexual men, sexual problems may require slightly differing conceptualizations based on factors such as alternative masculinity ideals (McDonagh et al., 2018).

Despite large-scale surveys such as NATSAL-3 beginning to broaden in scope, they still remained primarily focussed on sexual problems and function as the defining factor of sexual wellbeing. The focus on sexual activity and function as the key markers of sexual wellbeing meant that our understanding remained constrained within a biomedical lens (Bell et al., 2017; Syme et al., 2019). While these developments did reflect (and contribute to) increased understanding and acceptance of sex as relevant in all stages of life, rather than merely in youth, they have also set new expectations toward retaining sexual function and activity in later life, and stigma against those who do not conform to norms of intercourse and traditional heterosexual relationship structures. Furthermore, the focus on sexual function means that successful aging models have tended to remain centered around decline avoidance, rather than attempting to build more positive and inclusive approaches to aging and wellbeing (Sandberg, 2013).

Indeed, there is some qualitative evidence to suggest that some older adults take their (societally imposed) invisibility and irrelevance as an opportunity to be free from strict societal expectations of what their bodies, relationships, and sexual lives should be like (Towler et al., 2021). While lack of a sexual partner has been found to be a significant predictor of lower levels of sexual activity, functioning, and wellbeing (DeLamater, 2012; DeLamater & Moorman, 2007; Lindau & Gavrilova, 2010; Mitchell et al., 2013; Thomas et al., 2015), a qualitative study on single older women revealed that many were “single by choice” because they wanted to protect their independence and because of the perceived challenges of dating for older women (Fileborn et al., 2015a). Indeed, a number of studies suggest that the perceived potential to fall into caregiving roles acts as a barrier to seeking new relationships for older women in particular (Calasanti & Kiecolt, 2007; Malta & Farquharson, 2014; Watson & Stelle, 2011). Some women stated that sexual satisfaction would be important to them but for the absence of a partner, and that intimacy with a partner was perhaps the primary attraction of sex and partnerships in later life (Fileborn et al., 2015a).

Findings such as these have contributed to a shift in focus to defining the concept of sexual wellbeing. More multi-dimensional conceptualizations of sexuality and its meaning have begun to emerge, reflecting more contemporary understandings of sex as more than an act of reproduction, and sexual wellbeing as more than frequency of sexual intercourse. As our understanding of sexuality has broadened over the last decade, some researchers have moved away from a biomedical focus and begun to investigate factors such as sexual satisfaction and pleasure, self-esteem, and sexual wellbeing (Anderson, 2013; Graf & Patrick, 2014). The World Health Organization have suggested further research is required into defining the concept of sexual wellbeing (World Health Organization, 2010, p. 4), which they define as the interrelation of physical, emotional, mental, and social wellbeing in relation to sexuality. The growing recognition of the need to define sexual wellbeing has begun to build a more multi-dimensional understanding to include factors such as sexual self-concept, sexual assertiveness, sexual self-esteem, and relationship satisfaction (Birnbaum et al., 2014; Mastro & Zimmer-Gembeck, 2015; Mitchell et al., 2021). Qualitative research in particular has sought to take a less dysfunction-based approach and has instead highlighted the importance of intimacy and emotional closeness during sex (Kleinplatz et al., 2013; Sandberg, 2013). A qualitative study of women and men over 60 years old who had reported experiencing “great sex” found that connection, love, and feelings of caring contributed to optimal sexual experiences (Ménard et al., 2015). Similarly, the men in Fileborn et al.’s (2017) qualitative study indicated that sexual intercourse contributed to emotional bonding and intimacy. Recently, a model of sexual wellbeing in later life which included intimacy and emotional closeness factors was assessed across four European countries (Štulhofer et al., 2019, 2020). The authors highlighted how gender differences in how intimacy predicted sexual wellbeing (i.e. men’s intimacy predicted the female partner’s sexual wellbeing, but women’s intimacy did not predict their male partner’s sexual wellbeing) may reflect traditional gender roles, and the need for further analysis into potential culture-specific influences.

Indeed, acts which enhance feelings of closeness are not only important during sexual activity but may also be seen as sexual themselves in later life. A number of studies have found that older adults take a broader view of what constitutes sexuality (including shared hobbies, cuddling, and kissing) and that sexual pleasure may be derived more from intimacy than physical sexual activity (Bouman, 2013; Hinchliff & Gott, 2004; Wentzell, 2013). Research into the importance of sex in later life and sexual expression suggests that some older adults find aspects such as intimacy and emotional closeness to be more important than sexual intercourse (Fileborn et al., 2017, 2015b; Lee et al., 2016; Sandberg, 2013). In the Australian study “Sex, Age, and Me,” in qualitative interviews both men and women often challenged the notion that penetrative sex is the only form of sexual expression, and frequently privileged acts of affection and intimacy over intercourse (Fileborn et al., 2017, 2015b). Qualitative studies have also reported that even though sexual activities changed over time among older adults, intimate relationships remained satisfying and rewarding, with both men and women positioning commitment, love, and care as the most important aspects of an intimate relationship (Hinchliff et al., 2018; Tetley et al., 2018).

It is interesting that this seems to be the case for both men and women, when traditional ideals of masculinity tend to position male sexuality as concerned with only sexual performance and function (Plummer, 2005; Sandberg, 2016). In qualitative studies of younger age groups (reported means were 35–42 years old) male sexual desire was shown to be more similar to female experiences of sexual desire than previously thought, with contextual and relational factors such as lack of communication and emotional connection, and romantic, non-sexual touch impacting experiences of desire for heterosexual men (Janssen et al., 2007; Murray & Brotto, 2021; Murray et al., 2017). It is therefore important to explore qualitatively whether this may also be the case for older men. Some research suggests that this focus on alternative forms of sexual expression means sexual difficulties do not always have a negative impact on the quality of intimate relationships and psychological wellbeing of older adults, at least for some individuals, and that older adults can remain close with their partners by engaging in them (Hinchliff & Gott, 2004; Hinchliff et al., 2018). Some refer to this as “sexual wisdom,” a concept whereby sexual wellbeing in later life draws from sexual quality and intimacy, not quantity (Forbes et al., 2017). Forbes et al. (2017) found that factors such as relationship characteristics and the amount of thought and effort invested in sexual expression buffered the impact of age-related declines in sexual wellbeing.

Despite recent strides to expand our conceptualization of sexual wellbeing, there remains a lack of qualitative research into the sexual lives of older adults (Hinchliff, 2016; Sinković & Towler, 2019). Qualitative research has been highlighted as necessary to aid in the transition away from purely biomedical understandings of later life (Hinchliff & Barrett, 2018b): it is an essential tool to expand our understanding of sexual wellbeing to include, and elucidate, factors such as intimacy, emotional closeness, and relationship satisfaction. Much of the research has focused on “young old” (65–80 years old) participants, which may have contributed to (or perhaps been a product of) the field’s focus on sexual function and decline avoidance approaches to sexual aging (Hinchliff, 2016). Larger age ranges may instead build more of a transitional or developmental picture, in which changes to health and physical capabilities are experienced and adjusted to, and allow us to begin to build more inclusive and global approaches to sexual wellbeing. A review of the qualitative literature found that older adults often rationalize and accept sexual changes as “natural,” and that those who felt this way also reported feeling less distressed about sexual problems (Sinković & Towler, 2019).

In this study, we wanted to investigate whether older adults normalize sexual function issues as a “natural” part of aging. Would this sentiment be reflected by our participants, and if so, why might this be? Perhaps older adults have simply become accustomed to and expect change across various dimensions of their lives, and so are more accepting of change. Or, perhaps the meaning of sex shifts in later life, and therefore older adults may not view sexual functioning as important as other dimensions of sexual wellbeing, such as affection, intimacy, and emotional closeness, as suggested in previous research (Hinchliff & Gott, 2004; Hinchliff et al., 2018; Tetley et al., 2018). We also sought to further decouple sexual wellbeing from its focus on sexual activity and function, and so we aimed to explore and elucidate how older adults viewed the sexual changes they had experienced; the importance of penetrative sex, and whether its meaning changed with age; and how those who had experienced changes to their sexual lives expressed themselves sexually and maintained a fulfilling relationship. By building a multi-faceted picture of sex in later life beyond sexual function and frequency of intercourse, we can begin to develop sexual rights frameworks that espouse more positive and inclusive approaches to the aging process. We aimed to explore these possibilities, and so the research questions were as follows:

• How do older adults experience and perceive their sexual lives in later life?

• How do older adults feel about any sexual difficulties and changes they may experience?

• How important is sexual contact in later life, and what role does it play in older adults’ perceptions of their wellbeing?

• What is the role of intimacy and emotional support in coping with changes related to sexuality and difficulties with sexual expression and pleasure?

Method

Participants

Men and women aged over 65 and fluent in English were eligible for the study. Purposive, snowball and convenience sampling were utilized to reach potential participants. Participants were recruited from the University of Southampton research participation database, posters in local community centers and organizations, such as those concerned with wellbeing in later life, the LGBTQ populations, and/or community centers in areas with a high population of Black, Asian, and minority ethnic groups (BAME). These included LGBTQ cafés and bars, “Third Age” centers, as well as the local newsletters of organizations such as Age UK. Purposive sampling via targeted Facebook advertisements was used to reach those who identified as a sexual and/or ethnic minority. Thirty-one older adults agreed to participate (16 women, 15 men) in interviews that took place between April 2017 and February 2018. The majority were heterosexual, married/in a relationship, retired, and described themselves as physically active. Despite efforts via purposive sampling to recruit older adults from minority ethnic groups as above, all participants were Caucasian. Nineteen percent of the sample identified themselves as LGB (n = 6, 2 men and 4 women).

Measures

Demographics Questionnaires

The participants completed a paper-and-pencil demographics questionnaire in order to determine their age, gender, sexual orientation, relationship status, their level of education, occupation, and physical activity level (for demographics, see Table 1). Activity level definitions were taken from the NHS BMI calculator (National Health Service, n.d.).

Table 1. Demographic characteristics of sample (N = 31).

	M	SD	N	%
Age	73.94	6.50	-	-
Gender
Men	-	-	16	51.6
Women	-	-	15	48.4
Relationship Status
Single	-	-	5	16.1
Married	-	-	13	41.9
Widowed	-	-	5	16.1
In a relationship	-	-	8	25.8
Sexual Orientation
Heterosexual	-	-	25	80.6
Gay/Lesbian	-	-	4	12.9
Bisexual	-	-	2	6.5
Education
Secondary education	-	-	6	19.4
Post-secondary (A-Levels, NVQ3)	-	-	4	12.9
Vocational qualification (BTEC, NVQ4 and above)	-	-	6	19.4
Undergraduate degree	-	-	10	32.3
Post-graduate degree (MA, MSc)	-	-	4	9.7
Employment Status
Part-time employment	-	-	2	6.5
Retired	-	-	27	87.1
Self-employed	-	-	2	6.5
Industry
Business, Finance, or Insurance	-	-	1	3.2
Health or Social Care	-	-	11	35.5
Manufacture, Construction, or Agriculture	-	-	3	9.7
Public sector or Education	-	-	10	32.3
Transport, Retail, or Wholesale	-	-	1	3.2
Other	-	-	5	16.1
Activity Level
Inactive	-	-	2	6.5
Low-Moderate	-	-	10	32.3
Active	-	-	19	61.3

Interview Topic Guide

The interview questions were designed to address the research questions above, and based on knowledge gained from a review of both the qualitative and quantitative literature: as such they were deliberately broad (see Træen et al., 2017b, 2017a). The questions were designed to prompt discussion on participants’ recent sexual experiences as well as those throughout their lifespan, and also to encourage participants to discuss their experiences and perceptions of romantic relationships (see Online Resource 1 for full topic guide). For example, I (the first author) asked questions such as “What kind of relationship have you had with your body throughout your life?” and “How would you describe your sex life today?” Follow-up questions and prompts were used to facilitate a rich, in-depth discussion and encourage the participants to reflect on how their perceptions and experiences may have changed over the years.

Procedure

The participants recruited via the Facebook adverts completed one additional step in the research process. The link provided in the study advert directed them to a short survey to confirm their eligibility for the study and to enable purposive sampling via iSurvey, a survey platform developed at the University of Southampton.

Participants completed in-depth, semi-structured interviews lasting an average of 1.5 hours (ranging from 33 minutes to 2:01 hours). The interviews took place either in a private room at the University or in the participants’ own homes, according to participant preference, and were conducted by the first author (female, aged 27; see Online Resource 2 for reflexive statement). When participants arrived for the interview, they read through the information sheets, were given the chance again to ask questions and then completed the consent form and demographics questionnaire. The aim of the study was presented as “We would like to better understand the meaning of sexuality for individuals. How satisfied you have been and continue to be with your sexuality.” I informed the participants that the interview would be conversational in nature and that we were “interested in their story and perspective.” We did this to ensure participants felt enabled to take an active role in the interview and speak freely and openly.

While questioning was guided by the topic guide, the exact questions asked and the structure of the interview varied based on participant responses. Toward the close of the interview, participants were offered the opportunity to ask questions of their own or to bring up topics that had not been covered but that they felt were relevant to their sexual lives. I then debriefed the participants by restating the aims of the study, offering resources for support and thanked them for their time. Most participants seemed to relax and enjoy the interview, despite the potentially sensitive topic and the “outsider” status of the researcher. Some informed me that they felt the interview had helped them realize and consider aspects about their experiences they had not previously acknowledged. Participants were paid £20 as a thank you for their participation. Ethical approval was obtained from the University of Southampton ethics committee.

Data Analysis

Reflexive thematic analysis (TA) was used to analyze the data (Braun & Clarke, 2019). Analysis was led by the first author, and was conducted from a contextualist standpoint (Henwood & Pigeon, 1994; Tebes, 2005), which asserts that knowledge emerges from context. This meant that I paid particular attention to where accounts and opinions varied and contrasted, and interpreted the potential reasons for this. I began by reading through the transcripts to familiarize myself with the data and note my initial impressions. This was followed by coding the data inductively by unit of meaning, taking an experiential approach, keeping the study’s core aims and research questions in mind (e.g., experiences of sexual difficulties). During these initial stages, I noted down memos of my analytical impressions to maintain focus on the raw data. Then, after completing the initial coding of the first five transcripts, I began the early stages of analysis by identifying patterns across the data and generating a preliminary set of descriptive candidate themes, which were discussed with the coauthors. It is important to note that this was not used as a “framework” to apply to the remaining interviews, but it allowed me to begin identifying the dominant patterns across the data, look for cases that contradicted these patterns, and identify the context of these contradictions. This was done to ensure the analysis reflected the nuances of sexual experiences and behaviors and helped avoid the loss of individual voices. I revised these themes iteratively to accurately capture the data, and to reflect variation in perspective and experience between participants. Finally, the meaning of these patterns was interpreted and I began to generate researcher-derived themes, referring back to the memos created during the coding process where relevant. All authors met to discuss the interpretations and to agree upon the final thematic map. See Online Resource 3 for an extract from the coding manual.

Results

The themes presented explore the participants’ experiences and perceptions of sex and relationships in later life in relation to the aging process. They encompass how sexual changes are viewed and experienced as well as how older adults may continue to express their sexuality whilst accommodating for these changes. Three themes were generated: Sexual Changes are “Natural,” Sex is the Icing on the Cake, and Maintaining Sexual Connection and Relationship Satisfaction. The theme Sexual Changes are “Natural” encompasses the idea among our participants that sexual changes are a natural part of the aging process. In the second theme, Sex is the Icing on the Cake, we discuss the role sexual expression played in our participants’ daily lives and sexual relationships. In the final theme, Maintaining Sexual Connection and Relationship Satisfaction, we explore participants’ experiences and understandings of how to maintain a satisfying romantic relationship and sexual connection despite the sexual changes and problems that can be experienced in later life.

Sexual Changes are “Natural”

This theme focuses on the changes participants experienced in their sex lives as they got older. First, we discuss the changes related to sexual frequency, desire, and orgasm. Next, we discuss how our participants often rationalized these changes as “natural” and inevitable, and how this relates to the wider literature on sexuality in later life. Finally, we consider why older adults may view sexual changes as a natural part of the aging process, drawing on societal narratives which equate sexual expression with youth and why some may find a sense of comfort and acceptance by rationalizing sexual changes in this way.

For our participants, reduced frequency of sexual activity compared with their earlier years was a common experience, often tempered by appeals to the natural course of life or how ubiquitous these experiences were perceived to be among the older population. Alfred (73, gay) reminisced about the early days of his relationship; “It was like that then. But that gradually faded. I mean that happens for everybody, doesn’t it, as you get older. Your sex life gets less or maybe less intense.” Alfred was not alone in his experiences of reduced sexual intensity, though this manifested in different ways among our participants. Both men and women described themselves as less “consumed” by sex in their later years, offering them freedom from expectation and social pressure to be sexually successful. Rachel (67, heterosexual) noted that she felt she was able to enjoy platonic relationships with men now that sexual tension and expectation was out of the way; “Actually, it’s really lovely, you can actually relax in other company and actually talk to people without having that interfere, that sex vibe interfere with everything you’re doing.” This idea that older age could be seen as an opportunity to find freedom from expectations was developed further in the themes “redefining self-image” and “older people are seen as ‘past it’” presented in our previous paper (Towler et al., 2021). For example, Kate (69, lesbian) felt empowered to divorce her husband of 45 years and begin a relationship with a woman due to having “earned our freedom” in later life (Towler et al., 2021, p. 6). However, despite some participants finding freedom within their (societally imposed) sexual irrelevance, many held negative views on how youthful characteristics define societal beauty ideals. Alfred in particular emphasized how he felt shunned from social spaces as an older gay man, as “the gay world is to a large extent or to some extent anyway fixated on youth and beauty.” While Alfred speaks negatively of how society equates youth and beauty, he and many other participants seemed to have internalized these ideals. These findings highlight an interesting tension between the desire to challenge stereotyping and stigmatization of the aging process, and embracing the opportunity to redefine oneself away from societal gender and sexuality norms (Towler et al., 2021).

Changes to the experience of, or the ability to, orgasm was also a common experience (particularly for women), and these changes were sometimes presented as an explanation for reduced sexual frequency. Since difficulty reaching orgasm or lower intensity orgasms interfered with their sexual enjoyment, some women felt reduced motivation to engage in sexual activity:

I would say not as frequent, because … I used to have really intense orgasms, really good ones, and now they’re quite, they’re okay, but I’m aware of the loss, which is quite sad. And sometimes they’re really good, but other times they’re quite namby pamby really, I think, “Oh no, I want it back,’ because it was really good. (Lara, 69, bisexual)

Lara seemed to be grieving the loss of her sexual function. If we consider Lara’s experience in relation to the five stages of grief process (Kessler & Kubler-Ross, 2005), she may be somewhere within the bargaining or depression stages, whereby she is fully aware that things are different for her now but has not yet fully accepted the change, as indicated by her desire to regain what was lost. Lara’s sense of loss here also speaks to the concept of sexual wisdom (Forbes et al., 2017), whereby sexual quality, not quantity, becomes a more influential factor on sexual wellbeing in older age. Lara is not mourning the loss of sexual frequency, but the loss of the ability to reliably achieve a high-quality orgasm. Therefore, these findings further delegitimise the historical emphasis within sex research on sexual wellbeing as measured by sexual frequency and narrow definitions of sexual intercourse (Lorimer et al., 2019; Marshall, 2010, 2012). When Daniel discovered that he could no longer orgasm at all, he told himself that he needed to acknowledge that he is aging, the implication being that changes such as this are to be expected in later life. He seemed to find comfort in that view, describing himself as “lucky” that the changes he was experiencing were happening slowly:

No, I found it out and I thought, “Well, I’m an old man”, I’ve got to acknowledge this, I’m well past my three score and ten and things are probably going to get worse, if I’m lucky very slowly, which seems to be happening at the moment, I’m getting worse very slowly. (Daniel, 83, heterosexual)

Accepting sexual changes as a natural part of the aging process was prevalent both in the current study, and others reported previously. For example, a systematic review found that older adults who rationalized sexual changes and problems in this way seemed to be less distressed about the changes and reported a reduced impact on their overall sense of wellbeing (Sinković & Towler, 2019). Colin’s description of how his experiences of erectile dysfunction had little impact on his relationship because their sex life was already declining exemplifies this viewpoint:

It just sort of faded out with age, you know, as I say as we’ve got older because she would be, what, 70 now or somewhere about age 70, 72 and it just sort of died a natural sort of a thing which you would expect. (Colin, 86, heterosexual)

This thought process could also be seen in Alfred’s account of the sexual changes in his relationship presented earlier. Alfred’s husband had multiple sclerosis, and over time, he required increasing care until he passed away. It’s interesting here that although the cause of the sexual changes in their relationship lay outside of the aging process per se, Alfred was rationalizing the changes as typical of later life, hinting that thinking of sexual changes in this way leads to acceptance (“I mean that happens for everybody, doesn’t it, as you get older. Your sex life gets less or maybe less intense”). However, there was some indication that acceptance does not necessarily equate to satisfaction with the situation, or as Simon (75, heterosexual) put it; “I accept it but I don’t bloody like it, I don’t like it!” Terry, on the other hand, believed that sexual changes are not a product of age itself, but a result of how we are adjusting to the aging process. He highlighted the role of context, such as physical capabilities or attitudes toward sex, a sentiment shared by a few of our participants:

… but also don’t think that is a given, it doesn’t necessarily have to be that way. It depends on physical health and … other factors like the time, and … how you feel about things. But I don’t see why anything should deteriorate just because you get old, like you are still able to function. (Terry, 67, heterosexual)

Retaining good physical and mental health were influential factors which affected the extent to which a person experiences sexual changes and problems in later life, relating to the concept of “successful aging.” Some argue that successful aging narratives have pushed the notion of retaining youthful characteristics (such as high physical and sexual functioning) as an indicator of aging well, thereby contributing further to the stigmatization of later life as a time of “decline” and insufficiency (Marshall, 2010; Marshall & Katz, 2002; Sandberg, 2013). One example of this is our participants’ discussions of the menopause. Some participants positioned hormone replacement therapy (HRT) as a tool to help older women “retain their youth,” describing themselves as more buoyant and vibrant when on the medication. One such participant, Rosa, indicated that she thought that women who are not on HRT were – in contrast – uninterested in sex:

I don’t think sex if you are not on HRT matters too much for a woman, this is my perception. If you are on HRT, you have got to from time to time, because you are the same as you were when you were younger but perhaps not quite to the same extent, I would say. (Rosa, 73, heterosexual)

However, how do these successful aging narratives affect a person who is already experiencing poor health, or whose physical activity and mobility are compromised beyond their control? Perhaps it is a sense of perceived control which determines which viewpoint they identify more strongly with: the successful aging model or the natural aging model. Rosa’s comments above suggest that she conforms more to the successful aging model. For her, taking HRT is her way of exercising some control over her experience of the aging process. However, for those who do not (or cannot) feel in control of the changes that may occur in later life, perhaps identifying more strongly with the perception that sexual changes are normal and natural (whether consciously or unconsciously) offers a sense of comfort, as seemed to be the case for Alfred when he suggested a decline in sex in later life “happens for everybody.” Furthermore, Terry also seemed to be alluding to the element of control when he identified that attitude is a factor in adjusting to the aging process. Attitudes toward sex, what constitutes sexual expression, and still feeling that sex is important to the relationship were seen as important for maintaining a sexual connection and satisfying relationship despite sexual changes which may have occurred among our participants (see Maintaining Sexual Connection and Relationship Satisfaction). Lara discussed how making effort to cultivate sexual interest helps buffer the decline in sexual desire caused by changing hormones, further supporting the idea that positive attitudes toward sex and perceiving a degree of control play a role in how sexual changes are viewed and addressed; “But I think it’s a matter of keeping it going as well, otherwise it does totally go to sleep. As long as you keep on trying, you know, it keeps them alive a bit more.”

Sex Is the Icing on the Cake

Within this theme, we conceptualize domains of wellbeing in later life as akin to the layers of a cake. Based on the results presented here, we have begun to develop a way to conceptualize sexual wellbeing in later life termed a “recipe for sexual wellbeing” (see Figure 1). As the analysis for this theme progressed, we noticed similarities between our findings and Maslow’s Hierarchy of Needs, and so this theory became a useful lens through which to view the concepts that were beginning to develop. The Hierarchy of Needs is a psychological theory which constructs human motivation in a series of stages toward self-fulfillment and wellbeing (Maslow, 1943, 1970). Maslow proposed that we must satisfy each level before moving onto the next, beginning at the lower order needs such as physiological and security needs (shelter and food) and ending with the highest order need of self-actualization (growing to one’s full potential). With blueprints similar to the Hierarchy of Needs, we present an argument that sexual activity in later life is a higher order need, built on foundations of companionship, emotional intimacy, social belongingness and security needs. Sexual needs come to the fore when these other domains are satisfied. As Violet expressed, sex is the icing on the cake of a fulfilling intimate and companionate relationship:

Figure 1. Recipe for sexual wellbeing.

You both feel the same way and it’s … just something you dearly want to – we would have a lovely evening together and that would be the – we’d go to bed and that would be just the icing on the cake. (Violet, 83, heterosexual)

For our participants who were not currently in a relationship (typically because they were widows/widowers), they often felt that sex was not important to them at all. Even though sex was important to Violet when her partner was alive, she no longer felt it relevant to her life as a widow: “Oh yes, now it doesn’t mean anything. Well of course I’ve got no partner now and I haven’t done for the last ten years, you know?” Similarly, Bryony described herself as newly independent, and that she would not be looking for someone else to “look after.” She was enjoying spending her retirement on her hobbies with friends; “I’m … got lots and lots of interests … do quite a lot. Um, fulfil my life that way without fulfilling it as a … with anybody in it, apart from various different friends I have.” For her, sex held no interest at all. But toward the end of our conversation, she explained that that may well change if the “right” person came into her life, suggesting that she’s simply not ready yet to actively seek a relationship and move beyond companionship.

It’s not important at all to me at the moment but if I suddenly met somebody who really did strike me as a … you know, a good chap, and I felt that I could carry it on further, it probably would be important. But in my state of mind at the moment, it doesn’t have any bearing or interest for me at all. (Bryony, 81, heterosexual)

As mentioned above, perceived control seems to play a role in a person’s approach to the aging process – whether they strive to retain or accept changes as “natural.” However, it seems to be playing an important role for Bryony’s approach to restructuring her life after her loss as well. Since losing her husband, she has become more concerned with piecing her life back together and satisfying her, what Maslow would describe as, “lower level” needs, such as a social support network. At the time, those were the aspects which were within her immediate locus of control. As these domains are becoming more secure, perhaps her locus of control is beginning to expand – and so she’s beginning to consider her next steps up the layers. Both Bryony and Violet are alluding to sex being something “more” in later life, built on more fundamental layers of fulfillment and enjoyment of life. Taking Violet’s analogy of sex being the icing on the cake, if overall wellbeing is the “cake,” it is complete (or “iced”) when a good quality sex life is included, but lack of it does not necessarily affect the layers below. Indeed, the underpinning levels may become even more important, as without them the structure would not be secure: “I mean I think it is more important at my age to be – and he would agree with this I think – it is the love and the companionship and closeness and compatibility is more important than the sexual act.” This account by Rosa (73, heterosexual) of her and her husband’s attitude toward their relationship is consistent with previous qualitative findings which suggest that love, care, and affection become the most important aspects of intimate relationships in later life (Tetley et al., 2018).

Perhaps in later life, sex becomes less important because individuals may experience or perceive more threats to the foundational level domains of the hierarchy such as security and belongingness, for example, if they lose a partner or become unwell. Alfred (73, gay) indicated that there is a perception among older adults that when someone loses their partner they lose contact with their couple friends; “People will say when, if you’ve been in a couple, and then one of you dies, you get dropped by all the other couples.” On the other hand, sex and desire in our younger years may feel more like a need (see Sexual Changes are “Natural”) simply because these lower-level domains are perceived to be more secure and more easily satisfied. Therefore, the need for sex becomes the most salient. For those who experienced change to the lower levels, like Violet and Bryony, sex was not a priority as they were concerned with finding ways to fulfil these more fundamental needs first, and these lower-level needs were the domains that were within their immediate locus of control. However, for those who still have their health and satisfying relationships, sex is the next priority need to fulfil, and it is within their locus of control to seek it. As Rosa indicated, companionship becomes more important than sex as we get older, and is the foundation upon which sex rests.

Indeed, positioning sex at the top of the “cake” does not mean it is the aspect which seems the most important to everyone. Goebel and Brown (1981) critiqued Maslow’s hierarchy of needs as a roadmap to stages of development due to their findings that older adults rated security need (a lower-level need) as most important. This does not necessarily contradict the structure of the model, only the idea that the topmost layers become the most salient as we move up the steps at all stages in life, or that we do not move up or down the steps based on events in our lives. Indeed, our own findings suggest that older adults’ perceptions and experiences are much more fluid than the original hierarchy allows for. In a more recent rendition of Maslow’s hierarchy, Kenrick at al. also placed sex toward the top of the pyramid and described the levels as overlapping, instead of stacked, suggesting that lower-level motives continue to be important throughout life, depending on the individual’s attitudes and life experiences (Kenrick et al., 2010). Older adults may simply have rated security as most important because it is the level which is under the most perceived threat in later life. Our findings here reflect that the topmost layer is not necessarily the most important or salient to a person’s wellbeing, particularly if a few layers have become insecure or eroded completely. Instead, it seems to be that we are most concerned with whichever factors are within our immediate locus of control.

Both men and women in the current study made reference to the concept of sex being “the icing on the cake” in their accounts. Although Simon (75, heterosexual) bucked the trend slightly in that he would “settle for just sex,” he is still suggesting that his goal is not just a sexual relationship, but one built on layers of emotional intimacy; “I’ll settle for sex in the sense if I can’t have love with it, maybe that’ll come in my next relationship but that’s what I want, I want a loving, sexual relationship, I want to feel loved.” Interestingly, his description also opposes the common stereotype, typically pointed at young heterosexual men, that male desire focuses on intercourse and conquest, devoid of emotion and intimacy. Sandberg’s (2016) study found that men described desire in their youth as “hot-blooded” and uncontrollable, focused on erection and ejaculation, and they conceptualized desire as emerging from the body. She interpreted these findings as her participants’ way of “doing masculinity,” referencing these stereotypes of male sexuality as dominant and intercourse focused. However, her participants also described how sex became less penile-vaginal intercourse-focused over time and how intimacy became more important. Simon’s account is consistent with previous qualitative work which suggests that feeling desired, shown in various ways such as romantic, non-sexual touch, is an integral part of intimate relationships for men (Murray & Brotto, 2021; Murray et al., 2017; Sandberg, 2016). Evidence seems to be mounting, then, that male and female experiences of desire are not as different as common stereotypes would lead us to believe. Therefore, when we have a fulfilling sexual relationship, we feel “complete” and well-rounded, and our participants seemed to be describing it as if it were the final piece of the puzzle:

I missed out over those years I suppose we’re talking probably 14/15 years in total, the time before my first wife and I got divorced and the time that I hooked up with Joanne, it would be 14 or 15 years and it’s a pretty bloody wonderful feeling actually when you feel more complete. (Rick, 73, heterosexual)

In addition to our “recipe for sexual wellbeing” suggesting a route to overall wellbeing in later life, our conceptualization also attempts to explain the variance in how important sex is to different people in later life. When we achieve the feeling of completeness that having a fulfilling sexual relationship provides (or when the cake is “finished”), we will strive to stay there. If our icing begins to melt or erode, we will try to make it right again. However, if an important life change happens, such as the death of a partner, and a few of the layers of our cake are now missing, we are no longer concerned with (or in control of) the icing in that moment. Instead, we would go about fixing the cake by baking some fresh layers and building them back up again. Once our sense of wellbeing has regained a stable structure, we can then aim for completion, or icing the cake; “It completes the loop, the circle of a relationship, it’s that final step into the intimacy of being close to somebody and it’s fun, we have a lot of laughter as I said.” (Kate, 69, lesbian)

Maintaining Sexual Connection and Relationship Satisfaction

Those who had experienced sexual problems and changes generally discussed the impact on their romantic relationships with a sense of agency. Even if they experienced limited success with pharmaceutical treatments (e.g., “I haven’t ever found them to be miraculous, let’s say … ” Peter, 67, bisexual), participants rarely felt completely powerless: a state they tended to attribute to their efforts to nurture their relationship and thus maintain its quality. Emotional connection, support, and communication buffered the impact of sexual changes on personal wellbeing and their relationship:

To have his … him literally beside me but beside me in terms of openness and support for any doubts, explorations, curiosities, whatever, that I was talking about, going through, for him to be very accepting of that and never ever critical of me or my sexuality or my performance or whatever. (Vanessa, 75, heterosexual)

Discussing the role her partner had played in helping her to adjust to the changes she had experienced as she’s aged, Vanessa highlighted the importance of openness, support, and lack of judgment, a sentiment shared by all of our participants to some extent. The ubiquity of these perceptions and the readiness with which our participants discussed them emphasizes that these are key factors to maintaining relationship quality and satisfaction in later life. Laying blame and concealing one’s feelings about themselves, their relationship, and their sex life are described as the antithesis of this:

I think that if you were in a sexual relationship and you didn’t understand and talk about it, it could lead to differences of opinion, blame and such like and so forth, and I think Nancy and I both being old enough to understand life shall we say that … if you don’t talk about things, you can … start to build brick walls … if you were in a relationship and you didn’t get fulfilment shall we say and you didn’t talk about it, it could lead to some serious problems I think. And Nancy and I found that we can talk about it. (James, 79, heterosexual)

James’ reference to “being old enough to understand life” positions this approach as a form of wisdom, whereby his understanding of relationships has been formed by a lifetime of experience. Once again, we draw links between our participants’ experiences and the concept of sexual wisdom (Forbes et al., 2017), which states that aging is associated with the acquisition of skills that buffer the impact of age on sexual wellbeing, such as by focusing on sexual quality, not quantity. It seems that this might extend to relationships in general. Indeed, James is suggesting that relationship quality also buffers the impact of sexual changes in later life. He hedged his discussion of the impact of lack of sex on a relationship by citing the importance of communication. Therefore, he is indicating that it is not lack of sex in itself that leads to problems in a relationship, but lack of discussion and communication with a partner. This finding links back to and supports our findings presented in the previous theme, Sex is the Icing on the Cake, whereby sexual wellbeing is built on a strong foundation of intimacy, emotional closeness, and companionship.

However, not all of our participants found that communication came easily to them and their partners. Daphne described how her partner used to take discussion about sexual problems and issues within the relationship as personal criticism:

But our sex life probably would have been better if he wasn’t like it which is sad because, you know, you can’t really discuss things. I think we can discuss things more now, I don’t think he’s quite as sensitive now. (Daphne, 68, heterosexual,)

As previous qualitative studies also suggest, Daphne is indicating that being unable to discuss sexual problems with a partner has an impact on the relationship quality and sexual wellbeing (Hinchliff et al., 2018). She described feeling that her partner had become more relaxed with age, and easier to talk to about sexual changes. This originally manifested in sexual problems, but they have managed to stay somewhat active now that they are having more open discussions. Their problems seemed to come from a place of lack of understanding and communication of the changes that each of them experiences, especially Daphne’s experience of menopause. Daphne experienced issues with vaginal dryness during and after the menopause, which she felt her partner dealt with in the wrong way – by buying sex toys. Daphne was reluctant to use them because they caused pain and discomfort for her, but she felt her partner did not understand and thought she was being critical of his attempts to help the situation. Indeed, a good understanding of what to expect and the appropriate solutions seem to go a long way, as indicated by our female participants who were in same-sex relationships. They described how they felt having a better understanding of each other’s experiences than other (heterosexual) couples might mean that sexual changes had little impact on relationship and sexual quality:

I think it’s useful if you’re both feeling the changes, or at least to some extent. I don’t mean necessarily at the same level, but at least aware of them. Because I mean I don’t really know how men change to that extent, but some men just don’t seem to lose it at all do they? They just seem to keep their sex drive going and I think that must be quite difficult. (Lara, 69, bisexual)

When Alfred’s husband’s condition deteriorated to the point where they could no longer have sex, they agreed on an open relationship. He, too, stressed that communication and honesty with his partner were crucial to the success of the arrangement:

I mean there was never any question [of] am I leaving him or anything like that. I’d sworn to him true love … when I would come back from somewhere, the sauna or a party or something and I’d had sex with other men we had this rule you have sex with whoever and whatever you like but you must not hide it, you must tell the other one what you’re doing. (Alfred, 73, gay)

Like James, Alfred’s account indicates that it is not necessarily lack of sexual contact with one’s partner which affects the quality of the relationship. Alfred and his husband were able to maintain a strong bond because they set clear boundaries and expectations about honest communication. Furthermore, our participants indicated that not only can a strong romantic bond be maintained between partners despite reduced sexual contact, but a strong sexual connection as well. For those who were no longer sexually active, or whose sexual activity had significantly reduced, sexual connection could be maintained by shared memories and experiences, and a high-quality intimate and emotional connection.

It hasn’t affected the relationship. Because I get so tired, I go into a – I have a separate room and a separate bed. I take her a cup of tea in the morning at 7am and get in to her bed and we have a bit of a cuddle, nothing else (laughs) and I take her another one at 8am and then we decide what time we should get up. (Robert, 92, heterosexual)

Acts of service, affection and care are all ways our participants expressed their romantic love for their partners. These acts seem to nurture feelings of emotional closeness and intimacy between partners, which could otherwise get lost without sexual intimacy and activity.

I was always very keen on grooming him and doing his hair, he was only 67 when he died, so he wasn’t very old. So, I felt very close to him, I know we didn’t make love but I still feel we did things together and I always did things with him, but we didn’t actually make love and as I said, we always went to bed and we always cuddled up together, although nothing happened at the time, but I’ve got no regrets at all and I don’t think he had either … I don’t think he was able to have – make love or anything in those days, but I gave him as much love as I could. (Violet, 83, heterosexual)

Violet described how her sex life deteriorated in those days, though in hindsight she came to view these acts as part of her sex life. Simply being able to cuddle and remain close with her husband became the most important type of sexual expression she was able to share with him, though this only crystallized in her mind after her husband had died. It seems that sex in later life – a time when we may experience various changes to our romantic life, social life, and physical abilities – can become about more than simply sexual intercourse. Instead, sex can be viewed as a continuum of behavior and feeling, the idea that sensuality and sexuality mean more than just sexual acts. Sexuality can encompass shared interests, feelings of “togetherness.” Indeed, Barb also made reference to this same attitude in her discussion of her sexual life with her husband in recent years.

And I do feel that experience, quite sensual things like a beautiful walk, seeing the deer on the golf course and sharing that sort of thing, singing together … It’s not sensual or erotic? I don’t know, it’s on a sort of continuum, isn’t it? We like nice foods. Jim cooks for me, that’s quite nurturing and keep that going. We enjoy films together. So, and politics is the same, that means a lot to me as well. So, we share that, we like to vote together and so other things take a sort of – sex, sexuality takes a backseat to other things. I think, I don’t know about aging. I mean it’s very different for everybody, isn’t it? But I am very aware of it and how it’s changing and how my tastes are altering. I can see changes in myself. (Barb, 77, heterosexual)

Our participants’ accounts support the findings from previous research, whereby older adults maintained a feeling of closeness with their partners through acts such as cuddling and expressed that aspects such as love and companionship became more important to relationship quality than sexual activity in later life (DeLamater & Koepsel, 2015; Hinchliff & Gott, 2004; Hinchliff et al., 2018; Tetley et al., 2018). The attitudes expressed by our participants and in the previous literature support the “affirmative old age” model, which positions later life as a time not of decline, but simply of difference (Sandberg, 2013). When we understand and accept the differences which aging bodies bring without a sense of loss, we may adapt to and appreciate the new experiences later life brings. In this way, the affirmative old age model, too, could be seen as a way to maintain a sense of control. When we cannot exert control over our bodies in the way proposed by the successful aging model, we can instead retain control regarding our attitudes to the changes and whether we see them as “decline.” Therefore, the sensual and intimate acts described by our participants serve as an acknowledgment of the experiences which were once shared together, and that these experiences have now broadened to include new ways of sensual and sexual expression: “Even if the sexuality’s just talked about or expressed in cuddles or memories or something, it’s still there, isn’t it, acknowledgement of a bond between us.” (Vanessa, 75, heterosexual).

Discussion

In this study, we investigated four main research questions; how do older adults perceive and experience their current sexual lives, how have they experienced any sexual changes or difficulties, how important is sexual contact in later life to wellbeing, and what role did intimacy and emotional support with a partner play in their experiences? We found that our participants did seem to rationalize changes to their sexual lives as part of the natural life course, though this sometimes depended on whether they felt they had control over the changes they were experiencing. When the changes were perceived to be out of their control, seeing the changes as natural seemed to bring a sense of comfort and acceptance. Using Maslow’s Hierarchy of Needs as a lens through which to conceptualize our findings on the importance of sex and the role it plays in later life, we conceptualized a route to sexual wellbeing for older adults termed a “recipe for sexual wellbeing.” We found that sex in later life is a higher order need – or the “icing on the cake” of a person’s sense of wellbeing – built on a foundation of intimacy, romantic feeling, companionship, and security. Once these foundations are satisfied, sexual contact becomes the final facet to secure. Finally, our participants generally felt that the impact of sexual changes on a relationship can be buffered or mitigated by open communication, intimacy, and emotional connection with a partner.

The rationalization of sexual changes as “natural,” espousing acceptance, is congruent with the previous literature (Sinković & Towler, 2019). Based on our findings, the normalization of sexual changes in later life seems to go hand-in-in hand with the shifting meaning of sex in later life, taking a broader view of what is sexual and placing greater importance on affection, intimacy, and emotional closeness. Rather than later life being seen as a time of sexlessness, current generations of older adults may now expect to experience changes to their sexual life whilst retaining some level of sexual expression, perhaps due to increased physical health and wellbeing in later life, better access to treatments for sexual problems and chronic conditions (DeLamater & Moorman, 2007; Lindau & Gavrilova, 2010), and shifts in societal attitudes toward diverse sexual relationships and experiences (Syme, 2014; Træen et al., 2016). However, aspects such as perceived control and relationship satisfaction seem to play a role in the extent to which older adults perceive it this way, or whether they subscribe to the successful aging model of decline resistance. As one of our participants pointed out, acceptance and normalization of sexual changes as “natural” does not always equate to satisfaction with the situation. This begs the question: is a person truly accepting and at peace with their situation, or do they simply feel that they have no other option? This is an important consideration for healthcare professionals and relationship therapists working with older adults, who should aim to provide help and support where possible whilst also being mindful not to problematize a situation on their clients’ behalf.

A potentially useful tool to help healthcare professionals and therapists navigate this issue can be proposed based on the findings of the current study. While previous research has found that the importance and meaning of sex can shift in later life to focus less on quantity and penetration, and more on emotional closeness and intimacy (Forbes et al., 2017; Hinchliff et al., 2018; Tetley et al., 2018), we expand on these concepts and suggest a “recipe” for sexual wellbeing in later life. This concept could be applied in healthcare and therapeutic settings as it attempts to explain and understand the variance in the importance of sex between individuals. It might also be used to plot a course toward enhancing sexual wellbeing that does not over-medicalize or problematize sexual changes. However, it is important to note that this concept is not intended to be prescriptive – that is, we do not suggest that sex is imperative and that older adults “should be” striving for it. Instead, this conceptualization emphasizes that a fulfilling romantic relationship, emotional connection, and strong social support are important factors to overall wellbeing in later life, and that sexual wellbeing can be achieved despite changes to sexual function and frequency. We suggest that future research explore this concept further, to test its applicability to demographic groups and contexts not featured within the current study.

Interestingly, we did not find much variance between the accounts of older men and women for any of the themes presented here. Common stereotypes among popular culture and the scientific community alike seem to assume that there is little complexity to male sexuality beyond sexual functioning, and that men’s ability to “perform” signals sexual satisfaction and desire (Plummer, 2005; Sandberg, 2016). Though greater attention on sexual functioning and the rise of pharmaceutical treatments for men does help to dispel earlier stereotypes of sexlessness in later life (at the risk of being labeled “dirty old man,” however), the lifelong sexuality discourses risk oversimplifying sexual desire and sexual wellbeing in later life. Previous research into sexual desire in younger heterosexual men found male desire to be more complex and more similar to female experiences of desire than previously thought, with men highlighting the importance of non-sexual touching and emotional connection (Janssen et al., 2007; Murray & Brotto, 2021; Murray et al., 2017). Our findings suggest that this is also the case for older men (the one exception being Simon, who stated he would “settle for just sex”). However, despite this statement, his account still supports the idea that older adults desire a sexual relationship built on foundations of intimacy and emotional connection (see Sex is the Icing on the Cake).

Finally, our findings provide further support for the theoretical concepts of affirmative older age and sexual wisdom (Forbes et al., 2017; Sandberg, 2013), and suggest that practitioners should take a more holistic approach to sexuality in later life which does not solely focus on sexual function and intercourse. Our findings largely support taking a more affirmative old age approach, which advocates for seeing later life as a time of difference, rather than a time of decline. However, while we remain critical of successful aging narratives due to their tendency to over-emphasize decline resistance, our results highlight that these approaches to aging may also have some positive aspects. As discussed in Sexual Changes are “Natural,” both the (successful aging-aligned) approach of retention and the (affirmative old age-aligned) approach of accepting changes as “natural” may have helped participants retain a sense of control over their wellbeing and sexuality in later life. Therefore, perhaps these approaches should not be seen as a binary, but as complementary.

Rather than two theories at odds with each other, our results suggest that successful aging and affirmative aging are instead merely two sides of the same coin. Though they may espouse different approaches to aging (decline resistance vs. acceptance of later life as a time of new and different experiences), they do not necessarily contradict each other. Indeed, our participants often referenced both concepts, identifying somewhere along the scale between them, or more strongly with different concepts in different situations. Instead, it seems to be perceived control that determines which approach older adults identify with: would striving to maintain their bodies afford them a greater feeling of control, or should they let go of striving for “youth” and eschew decline narratives? When we cannot exert control over our bodies and the aging process, perhaps we can control how we perceive the changes we experience. The concept of perceived control seemed to be the common thread which connected the concepts of affirmative old age, successful aging, and individuals’ own recipe for sexual wellbeing in later life. As discussed regarding the theme Sex is the Icing on the Cake, whichever layers are currently within a person’s locus of control seem to be the ones deemed most important. While certain levels may not have been within our participants’ locus of control at the time (and therefore deemed unimportant), they showed an awareness that this may not necessarily be the case in the future.

Strengths and Limitations

Our efforts to recruit a diverse sample were successful and we recruited and interviewed LGBT and “oldest old” participants. These groups have thus far been underrepresented in the qualitative literature on older adults’ sexuality, which has tended to focus on heterosexual and “young old” participants (Sinković & Towler, 2019). Recruitment of these groups was aided by the use of several different sampling methods such as purposive sampling via paid advertisements on social media. We believe that this approach enabled us to build a more transitional and developmental insight into the aging process, and a more multi-faceted picture of sexual wellbeing in later life. However, we also acknowledge that there may be generational differences in experiences between participants in their 60s and those in their 80s. Additionally, while the inclusion of gay, lesbian, and bisexual individuals enriched diversity of experience in the current sample, further research which focuses on these groups would enable greater insight into their unique experiences. This is particularly the case for older lesbian women, transgender, and non-binary individuals, as these groups are currently under-represented within the literature on sexual wellbeing in later life.

There were some limitations of the study. While we were able to provide an in-depth insight by the high level of representation of diverse sexual orientation and age, our sample was generally physically active and well educated, and entirely White. Our recruitment measures were successful in recruiting some underrepresented groups, but future research should explore alternative methods to improve recruitment of Black, Asian and minority ethnic (BAME) groups, and those who are less physically able. As above discussed, research which focuses specifically on these groups is required in order to elucidate their unique experiences and add to the evidence base of research in this area.

Furthermore, the interpretations made within the current study may be limited to the more liberal cultural context of Western culture. Indeed, previous studies of sexual wellbeing in later life in non-Western cultures have painted a more conservative picture based on traditional gender roles, and have focused on gender differences in sexual desire (Sinković & Towler, 2019). For example, some studies have reported that older women’s role in sex is characterized by obligation and passivity (Baldissera et al., 2012; De Araújo et al., 2013; Lagana & Maciel, 2010; Ravanipour et al., 2013; Yun et al., 2014). This stands in contrast to the results presented here, which were characterized by few gender differences and generally positive sexual experiences and attitudes for older women. More consistent with the current findings was a more recent qualitative study of older adults in India that reported that emotional closeness, companionship, and sensual, non-penetrative touch were the cornerstone of intimacy in their sample of men and women (Banerjee & Rao, 2022). There is a need for further research to be undertaken in non-Western cultures, especially considering the older studies above may not reflect current social attitudes and contexts.

Finally, as an interviewer my “outsider” status could also have resulted in impression management, whereby the participants may have sought to portray themselves in ways that they felt would be perceived positively (Braun & Clarke, 2013). However, generally I did not get the impression that this was the case, and in fact my outsider status seemed beneficial to the conversation in some cases. For example, when sharing their experiences of menopause, many women seemed to take on a mentorship role with me, giving advice and facilitating detailed and rich descriptions.

Conclusions

The findings demonstrate that our participants viewed sexual changes in later life as part of the natural life course. Factors such as intimacy, emotional closeness, and open communication gained importance over sexual intercourse and function, as well as helped to maintain relationship satisfaction and sexual connection in later life. We suggested a new conceptualization: a “recipe for sexual wellbeing” which attempts to understand the shifting importance of sex in later life. The findings from the current study suggest that aging narratives should take a balanced approach which focuses less on “successful aging” (as defined by decline and retention of “youthful” characteristics) and more on the affirmative old age approach which conceptualizes later life as a time of different and new experiences. These findings have implications for how aging and sexual changes are approached and discussed in healthcare and therapeutic settings. Future research should attempt to explore the applicability of the recipe for sexual wellbeing concept further.

Acknowledgments

The authors would like to thank all members of the Healthy Sexual Aging team for their support, feedback and inspiration throughout the project.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/00224499.2022.2093322

Additional information

Funding

This work was supported by Norges Forskningsråd under grant [250637].