Copyright 1997 by
The Cerontological Society of America
The Cerontologist
Vol.37, No. 1,6-14
This article explores the relationship between sociopsychological factors, sexual activity, and
sexual satisfaction in a sample of 1,216 elderly people (mean age = 77.3). Almost 30% had
participated in sexual activity in the past month and 67% were satisfied with current level of
sexual activity. Men are more likely to be sexually active, but less apt than women to be
satisfied with their level of sexual activity. Regarding predictors of sexual activity, for men the
strongest predictors were being younger and having more education. For women, the
strongest predictor by far was being married. For both men and women the strongest
predictors for satisfaction were being sexually active and having positive mental health scores.
In summary, the main variables predicting sexual activity were being married, having more
education, being younger, being male, and having good social networks. The main predictors
for satisfaction with sexual activity were, in addition to being sexually active, being female,
having good mental health, and better functional status.
Key Words: Elderly, Sexual behavior, Survey research
Sexual Activity and Satisfaction Among
Very Old Adults: Results From
a Community-Dwelling Medicare
Population Survey1
Ruth E. Matthias, PhD,2 James E. Lubben, DSW, MPH,2
Kathryn A. Atchison, DDS, MPH,3 and Stuart O. Schweitzer, PhD4
Regardless of age, sexuality can be one of the
human expressions that protects against alienation,
coldness, and terror of an instrumental cost-accounting culture; a connection with the humanity in people for the celebration of being alive (Croft, 1982).
However, empirical data on sexual activity among
healthy older adults is relatively limited. For example, a recently completed and highly publicized national study of adult sexual activity excluded those
over 60 years of age (Laumann, Gagnon, Michael, &
Michaels, 1994).
In the late sixties, there were several comprehensive studies pertaining to sexuality and older adults,
most evolving from a Duke University longitudinal
1
A paper presenting this research was delivered on November 2,1994 at
the American Public Health Association Annual Meeting, Washington, DC.
This study was part of a larger project funded by the Office of Research and
Demonstrations, U.S. Health Care Financing Administration (HCFA), #95C-99165/9-01. The total (direct and indirect) costs of the six-year project,
which ended April 30, 1994, were $1,932,000. Total reimbursements for
Medicare-waivered services were $404,300. HCFA funded 100% of the total
costs. Interpretations of the data are the authors' own and do not necessarily represent the official opinion of the Health Care Financing Authority.
The authors wish to acknowledge the assistance of Todd Franke, PhD, Fred
De Jong, PhD, S. Allison Mayer-Oakes, MD, and Claudia DerMartirosian,
MA.
2
University of California, Los Angeles, School of Public Policy and Social
Research. Address correspondence to Ruth E. Matthias, PhD, UCLA School
of Public Policy and Social Research, 3250 Public Policy Building, Box
951656, Los Angeles, CA 90095.
^University of California, Los Angeles, School of Dentistry.
•University of California, Los Angeles, School of Public Health.
study on aging (Pfeiffer & Davis, 1972; Verwoerdt,
Pfeiffer, & Wang, 1969a, 1969b). Twenty-five years
later, these studies need to be updated. There is a
need for more current research on aging and sexuality. Our article addresses this deficit in the research
literature. It reports on sexual activity and satisfaction among a large sample of relatively healthy Medicare beneficiaries. All study participants were asked
how satisfied they were with their level of sexual
activity and whether or not they had had sexual
relationships during the past month.
Sexual behavior has been scrutinized for many
years, yet we are just beginning to explore the association between sexual activity, interest, satisfaction, and other factors among older people. To date,
studies pertaining to older persons are not comprehensive. Most samples are very small and confined
to either males or females, and the age categories
vary widely. Roughan, Kaiser and Morley (1993)
summarized 12 studies of sexual functioning in
older women; seven had fewer than 152 respondents, and nine had minimum ages between 50 and
60. Only a few included both sexual activity and
sexual satisfaction.
We now summarize studies relating sexual activity
to various other factors such as age, marital status,
gender, and general and mental health status before
turning to the relationship between sexual satisfaction and other factors.
The Gerontologist
Predictors of Sexual Activity
Age would seem to be important when considering factors that can influence sexual behaviors. However, results are inconsistent. Starr and Weiner
(1981) found that sexual frequency among senior
center participants did not decline sharply with age,
but averaged 1.5 times per week for those in their
60's and 1.2 times per week for those over 80. They
concluded that frequency for people who remained
active did not differ that much from earlier data on
the same cohort, but if compared cross-sectionally to
a younger group at the same point in time, differences were significant. Similarly, George and Weiler
(1981) studied one cohort over time, and found that
most people's level of activity remained the same.
Other studies have found a relationship between age
and sexual behavior (Marsiglio & Donnelly, 1991). A
study of 806 veterans showed that sexual interest
declined with age; on a scale from one to five (five
indicating "extremely interested"), interest ranged
from 4.4 for those aged 30-39, to 2.0 for those aged
90-99 (Mulligan & Moss, 1991). Thomas (1991) had
similar results. It is possible that age, type of study
design (longitudinal vs cross-sectional), and possible
confounding of age with cohort membership, may
cause different study outcomes.
Marital status and gender are similarly inconsistent
predictors of sexual activity. Thomas (1991) reported
that sexual interest was not related to marital status,
whereas Diokno, Brown and Herzog (1990) showed
marital status to play a significant role in sexual behavior. From a sample of 744 elderly respondents,
Diokno and associates reported that 74% of the married men were active compared with 31% of the
unmarried men, and 56% of the married women
were active compared with 5% of the unmarried
women. This finding suggests gender as well as marital status differences. Regarding gender, George and
Weiler (1981) found that women reported significantly lower levels of sexual activity than men, although Marsiglio and Donnelly (1991) surveyed 807
over-60-year-olds and showed that gender was not
related to sexual frequency.
Health is a factor consistently related to sexual
behavior. According to Croft (1982), the two major
requirements for enjoyable sexual activity in later life
are an interested and interesting partner and reasonably good health. For some older people, infirmity is
a serious impediment. Mooradian and Greiff (1990)
found the absence of illnesses to be an important
factor associated with sexual interest among older
women. Sexual behavior also has been linked with
mobility (Diokno et al., 1990); diabetes, coronary
diseases, prostate problems, and renal dialysis (LoPiccolo, 1991); cancer, incontinence, and pulmonary
diseases (Mooradian, 1991).
Regarding sexual activity and mental health correlates, Thomas (1991) found that for 46 men aged 70
and above, sexual interest was related to measures of
personal identity and emotional expressivity, but not
to life satisfaction. Sexual behavior has also been
associated with a person's sense of self-worth/
Vol.37, No. 1,1997
competence, so that older people who had a higher
sense of self-worth were more likely to engage in sex
(Marsiglio & Donnelly, 1991). Other psychological
factors such as loneliness, depression, and cognitive
dysfunction may limit sexual activity (Labby, 1985;
Mooradian, 1991).
Predictors of Sexual Satisfaction
Fewer studies deal with factors related to sexual
satisfaction in older adults. Among the few which
have, findings regarding satisfaction's relationship
with age are not consistent. Age was not related to
sexual satisfaction in the Starr-Weiner report (1981),
where 75% of the respondents stated that sex was the
same as or better than when they were younger.
Elsewhere, being older was associated with higher
happiness ratings (Mulligan & Palguta, 1991). Malatesta, Chambless, Pollack, and Cantor (1988) studied
the interactive effects of multiple factors determining sexual satisfaction: barriers to sexual expression,
degrees of unhappiness associated with loss of
marriage-related activities, and age. Their sample
consisted of 100 widows, 60 of whom were more than
60 years of age. The younger widows expressed
greater unhappiness with the loss of sexual activities.
In general, sexual satisfaction in later life appears
to be related to sexual satisfaction in the earlier
years. Based on a study of 59 healthy married women
aged 60 to 70, Bachman & Leiblum (1991) found
that almost half of the sexually active women reported long-term satisfaction with their sexual relationships as opposed to only 11% of the abstinent
women. Adams and Turner (1985) show a significant
correlation between satisfaction in early and later
years, based on self-reports from 102 older adults.
A handful of studies explore the relationship between sexual activity and satisfaction. The StarrWeiner report (1981) showed that satisfaction was
related to orgasm. Another study showed that one
correlate of sexual satisfaction was intercourse, but
this study included only male nursing home residents (Mulligan & Palguta, 1991). Finally, a more
recent study showed that the strongest predictors of
satisfaction were problems with erections and sex
information, although this study was based on a
sample of only 77 men (Schiavi, Mandeli, &
Schreiner-Engel, 1994).
In summary, there is no known recent study that
has examined the relationship between sexual activity levels and sexual satisfaction in an elderly
community-dwelling population. Therefore, we can
only predict tentatively that there will be a relationship between sexual activity and sexual satisfaction.
We know more about factors related to sexual activity (marital status, general health and mental health
status, and age and gender, although the latter two
factors are less clear). Our knowledge is limited,
because overall, few studies incorporate demographic, social, psychological, and physiological factors as multiple predictors of sexuality. Accordingly,
the purpose of this paper is to explore the relationship between sexual satisfaction and sexual activity,
and their sociopsychological and demographic determinants among older adults living in an urban
setting.
Methods
Sample
The sample for this study is a group of 1,216 elderly
people participating in the UCLA Medicare Screening
and Health Promotion Trial (MSHPT). The MSHPT was
funded by the Health Care Financing Administration
to assess the implications of expanding Medicare
coverage to include preventive services. The sample
was obtained through referrals from UCLA-affiliated
physicians. The geographic locale is therefore Los
Angeles and its immediate suburbs. We received lists
of all patients eligible for our study from a group of 73
participating physicians. Additional details pertaining
to recruitment and sample design are described in
Hirsch, Mayer-Oakes, Schweitzer, Lubben, and De
Jong (1992). Telephone interviews using the Geriatric
Health Risk Appraisal (GHRA) instrument were conducted annually beginning in 1989. The GHRA included questions in the areas of general health, physical health, mental health, oral health, health-related
behaviors, social networks, and descriptive respondent characteristics. Criteria for inclusion in 1989
were that the participant be 65 years of age or older,
be seen by a physician in the last six months, be
English speaking, have a telephone, and have no
dementing disease or terminal illness. Data for the
present study are from the fifth annual telephone
interview, conducted early in 1993, at which time the
minimum participant age was 70.
Measures
Sexual Activity and Satisfaction. — This analysis is
based on two questions added to the GHRA in 1993,
"During the past month have you had sexual relationships?" and "During the past month, how satisfied were you with your level of sexual activity or lack
of sexual activity?" Responses were presented in a
Likert scale ranging from 5, "very satisfied," to 1,
"very dissatisfied." On the basis of this question
alone, it is not known whether the response pertains
to level of activity or lack of activity. The satisfaction
question was derived from the Functional Status
Questionnaire (Jette et al., 1986). In that questionnaire, there was a sixth response category, "did not
have sexual relationships." We deleted that response category since we had the separate question
on sexual activity. Thus, we were able to collect data
on sexual satisfaction for people who were not sexually active, as well as for those who were.
Because we realized that the topic may be sensitive, we prefaced the two questions with the statement, "Some people in their later years remain sexually active while others do not. The next two
questions pertain to this issue." This introductory
statement also served the purpose of clarifying the
meaning of "sexual relationship."
For concise presentation of data on satisfaction in
the bivariate analysis section, we combined very satisfied and satisfied into one category and very dissatisfied and dissatisfied into one category. "Not sure"
remained a separate category. Prior to collapsing, we
conducted all analyses with all 5 levels of satisfaction
(tables not shown). Overall, very satisfied and satisfied were similar enough to warrant collapsing.
While very dissatisfied and dissatisfied were not as
similar for some variables, they were enough alike to
collapse, especially considering the small size of the
very dissatisfied group.
In the multivariate analysis section, the satisfaction
variable was again collapsed into the three categories. Initially, multinomial logistic regression was
conducted with all 5 categories, but the results were
not useful. The multinomial logistic regression
model is based on the proportional odds assumption, and this assumption was not met until we collapsed the variable to three rather than five categories. The odds ratios, however, changed only slightly
between the five-category and three-category dependent variable. Thus, for the final logistic regressions, the dependent variable, sexual satisfaction,
was trichotomous (satisfied, not sure, and dissatisfied) and the dependent variable, sexual activity, was
dichotomous (active, not active).
The following independent variables have been
validated in previous studies, as indicated.
Mental Health. — Five items from the Functional
Status Questionnaire (FSQ) relate to mental health
status: "could not be cheered up," "felt happy,"
"felt down-hearted and blue," "felt calm and peacef u l , " and "felt nervous." These five are referred to as
the shortened form of the FSQ Mental Health Inventory (MHI-5) and represent the dimensions of anxiety, loss of behavioral or emotional control, and
general positive affect. The scores range from 0 to
100, with a low score indicating problems in psychological functioning and a score under 66 indicating
high risk (Berwick et al., 1991; Jette et al., 1986). Scale
items were re-ordered so that a 5 indicated fewer
problems. The items were then added together and
multiplied by 4 if no items were missing. Missing
values fewer than three were imputed. Otherwise,
the MHI-5 was coded as missing.
Social Networks. — The Lubben Social Network
Scale (LSNS) determines the quality and extent of
social networks, based on 10 items such as "number of close friends," "number of relatives seen
monthly," and "having someone to talk t o " (Lubben,
1988; Rubenstein, Lubben, & Mintzer, 1994). The
scale examines the size of the active network, the
size of the intimate network, confidante relationships, and frequency of contact. The adjusted scale
used in these analyses substitutes mean values for
missing values if only one or two items are missing.
Scores can range from 0 to 50, with low scores indicating weaker social networks.
Depression. — The Center for Epidemiologic
Studies-Depression (CES-D) scale measures depresThe Gerontologist
sive symptomatology in the general population
(Radloff, 1977). There are twenty items such as "felt
lonely/' "felt bothered by things," "felt hopeful for
the future," and "felt happy." Mean substitution is
used for missing values if fewer than five items are
missing. Scores range from 0 to 100 with high scores
indicating symptoms of depression. A score of 17 or
more indicates a high risk for depression (Radloff,
1977).
Functional Status. — The Basic Activities of Daily
Living (BADL; Katz & Akpom, 1976) scale is based on
five items from the FSQ pertaining to functional
status, with a focus on personal care tasks: difficulty
walking indoors, difficulty getting in and out of bed,
difficulty bathing, difficulty getting in or out of the
tub or shower, and difficulty dressing and undressing. The scale uses the response scores for the first
two items plus the one maximum score (most problems) from the latter three items. If one item is
missing, the scale is adjusted for missing values. The
FSQ BADL differs from the Katz and Akpom BADL
because the FSQ scale contains only those items
appropriate for a highly functional population. The
scale ranges from 0 to 100, with a low score representing problems with physical functioning.
The Instrumental Activities of Daily Living (IADL)
scale is based on seven items: difficulty walking a
quarter of a mile, walking up ten steps, doing vigorous activities, shopping, getting places, difficulty
with yard work or home maintenance, and difficulty
with light housework. For the last two items, only the
higher of the two scores was used. The FSQ IADL is a
modification of the Lawton and Brody (1969) and the
Nagi (1976) scales, and is used because it is more
appropriate for a highly functional population (Jette
et al., 1986). It is interpreted in a similar way to the
BADL scale.
Subjective Health Status. — Self-reported health is
a single item with responses ranging on a five-point
scale from 1, "excellent," to 5, "poor." "Worry about
health" is also a five-point scale ranging from 1,
"worry a great deal," to 5, "worry not at all."
General Health Status. — "Bed days" is the selfreported number of days spent in bed during the past
year due to illness or injury. The chronic conditions
measure includes responses to the question, "In the
past year, has your doctor told you that you had any of
the following?... high blood pressure, heart disease,
stroke, diabetes, cancer, chronic lung disease, arthritis, pain in legs due to poor circulation, kidney problems, and/or nervous or emotional disorders."
For bivariate analyses, Mests (for activity vs no
activity) and analyses of variance (for three levels of
satisfaction) were used to determine differences in
mean scores of continuous variables, and chi-squares
were used to determine differences in proportions
for categorical variables. The multivariate analyses
were multinomial logistic regression for the threelevel dependent variable, sexual satisfaction, and
standard logistic regression for the dichotomous deVol.37, No. 1,1997
pendent variable, sexual activity. The SAS statistical
package was used for all analyses.
Results
Table 1 presents means and percentages on the
major study variables for the total sample, as well as a
comparison of those who responded to the sexual
satisfaction question and those who did not respond. For the sample as a whole, over half of the
participants were married and female, and half had
incomes over $30,000. The average educational level
was 13.6 years, and mean age was 77.3 years, ranging
from 70 to 94. Over one third reported "excellent" or
"very good" health and just under one third (29.5%)
reported having had a sexual relationship in the past
month. Over two thirds reported that they were
"very satisfied" or "satisfied" with their level of sexual activity or lack of sexual activity. On the basis of
this one question, it is not clear whether respondents were reporting satisfaction with level of activity
or with lack of activity. However, when results from
this question were cross-tabulated with the sexual
activity question, it is clear that more of those reporting satisfaction were referring to "level of activity"
rather than "lack of activity" (See discussion below
on Table 2 — satisfaction compared with activity).
There were only 31 who did not respond to the
sexual activity question, and there were no differences for any of the variables between the responder
and the nonresponder groups. A larger number (n =
93) failed to respond to the sexual satisfaction question, and there were significant differences between
the responders and nonresponders (Table 1, columns
2 and 3). Those who did not respond were more likely
to be female, not married, in a lower income category, less educated, more functionally impaired, and
to report poor health and sexual inactivity.
Tables 2 and 3 present differences between those
who were and were not sexually active, and between
those who were and were not satisfied with their
level of sexual activity. We conducted chi-square
tests with the dependent variables and several sociodemographic variables. Results in Table 2 show
that marital status is related to sexual activity, but not
to sexual satisfaction. Women were more highly represented in the sexually inactive group, with almost
twice as many inactive as active (66% vs 37%). However, there were significantly more women in the
satisfied than in the dissatisfied group (61% vs 34%).
Of the 625 women who responded to the satisfaction
question, only 66 reported being dissatisfied or very
dissatisfied with their sexual activity/inactivity. People in lower income groups were less likely to be
active, but income made no difference in satisfaction. Finally, self-reported health and worry about
health were both associated with sexual activity and
satisfaction, and satisfaction is related to sexual activity. Of those who were active, fully 83% were satisfied or very satisfied compared with only 59% of
those who were not active. Of those who were active, 9% were dissatisfied or very dissatisfied, compared with 21% of those who were not active.
Table 1. Means and Percentages on the Major Study Variables.
Total Sample, Responders and Nonresponders to the Sexual Satisfaction Question
Variable
Total
Sample
(N = 1,216)
Gender
% female
Marital status
% married
Income3
$0-14,999
$15-29,999
$30,000 +
Education — mean yrs. (SD)
13.6
Age — mean (SD)
77.3
Bed Days — mean (SD)
Responders
(n = 1,123)
Nonresponders
(n = 93)
57.4
55.7
78.5**
57.5
59.1
37.6**
18.7
30.4
50.9
17.4
31.3
51.3
38.1**
15.9
46.0
(3.3)
13.7
12.8*
(5.1)
77.2
78.4
6.1 (16.6)
6.3
9.1
IADL
72.8 (21.9)
73.6
62.9***
BADL
Self-rated health (%)
Excellent
Very good
Good
Fair
Poor
91.9 (14.1)
92.2
87.3**
10.3
25.1
35.8
21.9
6.8
10.8
25.6
36.4
21.3
5.9
4.4***
18.5
28.3
30.4
18.5
Sexual activity in past month 6
(% yes)
29.5
31.3
2.7*
Sexual satisfaction (%)
Very satisfied
Satisfied
Not sure
Dissatisfied
Very dissatisfied
14.9
52.0
15.7
12.1
5.3
Note: Means and standard deviations unless otherwise noted. Percents do not always add to 100 due to rounding.
For income, there are 215 missing values.
b
For sexual activity, there are 31 missing values, 20 of which are in the nonresponse category.
*p < .05; **p < .01; ***p < .001 (Mests and chi-square values).
a
Table 3 shows differences in mean scores of variables by activity and satisfaction. Those who were
active were younger and had more education, but
age and education were not related to satisfaction.
Two of the disability indicators, number of bed days
and BADL, and all the sociopsychological indicators
were related to both sexual activity and satisfaction.
People who were more disabled, who had more
negative mental health responses, were more depressed, and had poorer social networks, were more
apt to be inactive and dissatisfied.
Because of the attention that has focused on the
relationship between disease and sexual activity, we
also analyzed chronic conditions (table not shown).
Larger proportions of those not sexually active reported arthritis and poor circulation (p < .001), high
blood pressure and heart disease (p < .01), stroke,
diabetes, and kidney problems (p < .05). Slightly
higher proportions of the "not satisfied" people reported chronic conditions, with significant differences for emotional disorders (p < .01), stroke, and
kidney problems (p < .05).
Tables 4 and 5 show logistic regression results for
variables predicting sexual activity and sexual satis-
faction, respectively. In terms of "goodness-of-fit,"
each regression is shown with a "model chi-square"
value. This statistic tests the hypothesis that the set of
independent variables is not useful in classifying
individuals. A large chi-square and a small p-value
indicate that the variables are useful in classification.
In this study, all equations are useful and the fit is
good. All variables were entered into the equation at
the same time. The chronic conditions were deleted
from the final analyses because none were significantly related to the dependent variables.
The results for the total group (Table 4, first
column) support results from the earlier bivariate
findings: age, gender, education, social network,
IADL, and marital status were all related to sexual
activity. Specifically, males were almost twice as
likely as females to be sexually active, when controlling for all other variables in the regression. People
who were younger (as indicated by an odds ratio of
less than 1), with more years of education (as indicated by an odds ratio of greater than 1), and with
better social networks were more likely to be sexually active. Those who were married were almost 6
times as likely to be active as those who were not.
10
The Gerontologist
Table 2. Percentages of Sample Population in Selected Sociodemographic Categories,
by Sexual Activity and Satisfaction With Sexual Activity
Sexual Activity
in Last Month
Satisfaction With Sexual Activity
Active
(n = 350)
Not
Active
(n = 832)
Very Satisfied
Satisfied
(n = 750)
Not Sure
(n = 176)
Marital status
% Married
88.0
44.2***
60.6
52.8
59.2
Gender
% Female
36.6
65.6***
60.6
59.1
33.7***
Race
% White
91.7
87.3*
88.4
86.4
92.4
Income (in$1,000's)
0-15
15-30
30 +
7.3
24.3
68.3
23.9***
33.2
42.9
18.6
30.9
50.5
17.8
38.4
43.8
12.2
26.8
61.0
Self-reported health, %
Excellent
Very good
Good
Fair
Poor
14.9
30.9
37.4
14.9
2.0
8.3***
22.8
35.1
25.0
8.8
12.0
27.5
36.8
19.6
4.1
7.4
21.7
38.3
24.6
8.0
9.2**
22.1
33.3
24.6
10.8
Worry about health, %
Great deal
Some
Hardly any
None
6.0
42.0
26.9
25.1
11.3***
50.1
16.2
22.5
7.1
45.5
20.3
27.2
10.3
52.0
20.6
17.1
14.3**
49.5
18.9
17.4
Satisfaction with sexual activity, %
Very satisfied
Satisfied
Not sure
Dissatisfied
Very dissatisfied
19.0
64.1
7.8
8.6
0.6
13.1***
46.3
19.2
13.7
7.6
Variable
Very Dissatisfied
Dissatisfied
(n = 196)
Note: Total n's do not add to 1,216 due to missing values.
*p < .05; **p < .01; ***p < .001, based on chi-square values.
Table 3. Mean Scores for Selected Variables, by Sexual Activity in the Last Month and Satisfaction With Sexual Activity
Satisfaction With Activity
Sexual Activity in Last Month
Very Dissatisfied
Dissatisfied
(n = 196)
Active
(n = 350)
Not
Active
(n = 835)
Very Satisfied
Satisfied
(n = 751)
Not Sure
(n = 176)
Demographics
Age
Education (mean yrs.)
75.6
14.6
78.0***
13.2***
77.3
13.6
77.0
13.6
76.9
13.9
Disability indicators
Bed days
Falls
BADL
IADL
4.2
0.4
96.1
81.6
7.3***
0.6
90.0***
69.2***
5.2
0.5
93.4
74.4
9.5
0.6
90.8
72.5
7.4**
0.7
89.0***
71.9
Sociopsychological indicators
FSQ-mental health
CES-D-depression
LSNS-social networks
78.3
5.1
32.4
73.3***
8.0***
28.5***
77.7
6.0
30.4
68.9
9.2
28.5
69.9***
8.9***
27.8***
Variable
Note: Significance levels based on t-tests (activity) and ANOVA f-tests (satisfaction).
* p < .05; * * p < .01; * * * p < .001.
Vol.37, No. 1,1997
11
Table 4. Odds Ratios From Dichotomous Logistic Regression
Results for Sexual Activity in the Last Montha
Variable
Intercept
Gender (female = 0)
Age
Education
CES-D-depression
LSNS-social network
FSQ-mental health
IADL
BADL
Bed days
Self-rated healthc
Excellent
Very good
Good
Fair
Married (1 = yes)
Arthritis
Poor circulation
Model chi-square
p-value
Total Group
(N = 1,153)b
.10
1.76**
.93***
1.11***
.98
1.03**
1.00
1.01*
1.01
1.00
Males
(n = 496)
Females
(n = 657)
2.00
—
.90***
Intercept 1
Intercept 2
Gender (female = 0)
Age
Education
CES-D-depression
LSNS-social network
FSQ-mental health
IADL
BADL
Bed days
Self-rated healthc
Excellent
Very good
—
.99
1.13*
1.03
1.01
1.02*
1.02
1.02*
2.50
6.01*
.49
2.38
3.61
.83
2.22
3.75
.68
2.00
2.77
5.76***
1.06
.91
1.43
1.19
.91
.27
23.70***
112.9
.0001
Variable
.00**
1.11**
.97
1.03*
1.00
1.01
1.02
.98
340.6
.0001
Table 5. Odds Ratios From Trichotomous Logistic Regression
Results for Satisfaction With Sexual Activity'
.99
.96
217.4
.0001
Females
(n - 610)
.00***
.00***
—
.06
.19
—
1.05*
1.00
1.00
1.02
1.02**
.99
1.03**
1.00
.98
.93*
1.01
1.00
1.03***
.99
1.01
.99
1.69
1.34
2.25
1.76
1.32
2.60*
Good
1.61
1.38
2.13
Fair
1.60
1.16
1.36
1.47
1.95
4.60***
4.56***
4.22***
Model chi-square
p-value
'Predicts likelihood of being sexually active.
Total is less than original 1,216 due to missing values.
'Comparison group is " p o o r " rated health.
*p < .05; **p < .01; ***p < .001.
.01***
.02**
.28***
Males
(n - 488)
1.03*
.97
1.00
1.01
1.03***
.99*
1.02**
1.00
Married (1 = yes)
Sexually active (1 = yes)
.86
Total Group
(N = 1,098)"
188.0
.0001
102.5
.0001
.98
73.2
.0001
"Predicts likelihood of being satisfied with current level of sexual activity: either "satisfied" versus "not sure'V'dissatisfied" or
"satisfied'V'not sure" versus "dissatisfied."
"Total is less than original 1,216 due to missing values.
c
Comparison group is " p o o r " rated health.
b
*p < .05; **p < .01; ***p < .001.
However, when separate regressions were conducted for males and females, gender differences
were striking. Although education was significant for
both men and women, age, social networks, and
self-reported health were significant for men but not
for women. IADL and bed days were significant for
women but not men. The most outstanding difference was for marital status. Women were 24 times
more likely to report sexual activity if they were
married than if they were not, while men were only
about 1.4 times more likely to report activity if they
were married.
For the multinomial logistic regression predicting
satisfaction (Table 5), the dependent variable was collapsed from five to three categories of satisfaction.
Using a dependent variable with three categories accounts for two different values for the regression intercepts. The trichotomous logistic regression model indicates the chances of being in a satisfied category
versus not sure or dissatisfied, or of being in a satisfied
or not sure category versus a dissatisfied category.
Gender was a significant predictor for the total
sample, its odds ratio indicating that men were much
less likely than women to be satisfied with their level
of sexual activity. Mental health status and sexual
activity were the only items which were significant
predictors for the entire sample and for the separate
male and female samples as well. In all three regressions, those who were sexually active were about 4 to
5 times more likely to be satisfied. Other significant
predictors for the total group were gender, IADL,
BADL, and age. Those who were more likely to be
satisfied were female, had higher functional status
on BADL but lower functioning on IADL, and were
older. Age was significant for males, but not for
females. Less education and very good versus poor
health were significant predictors of satisfaction for
women but not men.
Discussion
There are three findings from this study which
make important contributions to our understanding
of elderly people's sexual behavior. First, regarding
satisfaction, sexual activity and mental health are the
most important predictors, regardless of gender. The
relationship between activity and satisfaction has
been noted in previous studies. What is interesting
in the present study is that one third of the sample
is sexually active, but over two thirds are satisfied.
These findings tend to support Marsiglio and Donnelly's conclusion from an earlier study that the importance of sexual activity may be minimal as long as
one is satisfied with the level of activity. In our study,
over half (59%) of those who were not active stated
that they were satisfied or very satisfied with their
level of activity (or inactivity).
Regarding the role of mental health in predicting
satisfaction, previous studies have tended to focus
on its relationship with satisfaction in earlier years.
Our finding adds another dimension to assessment
of sexual satisfaction in later life, one which is intuitive. If an older person has a positive mental health
status, it is logical that that person would be more
12
The Gerontologist
the separate gender analyses, the predictors of activity for men were being younger and having more
education; for women, the strongest predictor was
being married. Most striking was the odds ratio of
24:1 predicting sexual activity for married vs unmarried women. Although there were differences between men and women for levels of satisfaction, the
two strongest predictors of satisfaction were common to both men and women: having good mental
health and being sexually active.
Generalizations about elderly people in the community must be made with caution from this nonrandom sample. One limitation is that our sample participants have high levels of income and education. A
second limitation is that a key question in this study
asked whether the person has had a "sexual relationship," and this term could be interpreted differently
by different people; it is not as explicit as "sexual
intercourse." Because the preface to the two sex
questions stated that both questions would be referring to people who may or may not "remain sexually
active" in their later years, we are assuming that
respondents here equate sexual relationships with
sexual activity, having heard both words as part of
the question. And, since our study focused more on
sexual "activity" and the satisfaction derived from it,
this somewhat broader question is entirely appropriate. For the purpose of this study, it is more important to know whether people deem themselves as
having had sexual activity or sexual relationships,
than whether they refer to actual "sexual intercourse," a more explicit concept which may not even
be a useful term for this age group.
A final limitation is that our sample was composed
of those aged 70 and over. Comparisons with
different-aged samples may not be justified. For example, in one study of over-60-year-olds, 66.6% of
the men and 31.7% of the women said they-were
sexually active (Diokno et al., 1990); however, in our
sample of over-70-year-olds, 43.6% of the men and
18.9% of the women indicated sexual activity.
One implication of this study is that caregivers and
health practitioners should be willing to acknowledge that sexual activity and satisfaction are associated with physical, social and mental aspects of functioning. Old people are not asexual.
On another level, those who are involved with
research issues in gerontology should also acknowledge the importance of sexual behavior, until now a
neglected area of gerontological research. This study
answers some questions, but raises many more. For
example, are older adults really satisfied with their
sexual activities or are they just accepting a situation
they perceive as offering few alternatives? Would
findings be consistent if the study were replicated in
different social strata or in different geographical
areas? Regardless of the direction of future research,
our results indicate that sexual activity and sexual
satisfaction could well be important additions to
well-being measures. As quality-of-life measures
continually expand to include mental and social aspects, we should no longer ignore sexual activity and
satisfaction.
satisfied with his or her sex life, regardless of the
level of sexual activity. When we recalculated mean
FSQ mental health scores by degree of satisfaction,
controlling for sexual activity, we found that FSQ
mean scores still differed among the five levels of
satisfaction. Higher scores were associated with
higher satisfaction, regardless of activity. These results parallel a previous study in which sexual problem scores among sexually active adults were highest
for depressed patients (Sherbourne, 1992). Our
study, then, adds to these earlier findings by including older adults who are and are not active sexually.
A second finding was that marital status had a
strong association with sexual activity for females,
but not for males. Previously, marital status has been
shown to play a significant role for both men and
women (Diokno, Brown, & Herzog, 1990) with married men being two and one half times as likely as
unmarried men to be sexually active, and married
women being over ten times as likely as unmarried
women to be sexually active. Our results show less
difference between married and unmarried males,
and more of a difference between married and unmarried females. When controlling for gender by
including it as a predictor variable in the logistic
regression equation for the total group, marital status was a significant predictor. However, 46.7% of
the married men had sexual activity in the last month
compared with 31.0% of the unmarried men, while in
contrast, 42.7% of the married women were active
compared with 2.7% of those who were unmarried.
When regressions were conducted separately for
men and for women, marital status was significant
only for females. It is possible that discrepancies in
previous studies regarding marital status and sexual
activity may be due to inadequate control of related
variables.
One reason that marital status is more strongly
related to sexual activity for women than for men
may be due to the double standard that men may
have sexual relationships outside of marriage, but
women may not. A double standard allows older
men to purchase sex without the guilt or social disapproval that it would create for older women. It could
also be due to another double standard of aging —
women become sexually ineligible at a much younger age than men, due to the societal value placed on
women's physical attractiveness which does not
stand up as well over time as the perceived "masculine" characteristics of independence and wisdom
(Croft, 1982). On the other hand, it simply could be
due to the fact that there are many more unmarried
women than unmarried men.
A third finding relates to a question that has not
been previously explored; that is, which variables
predict satisfaction and which predict sexual activity.
The results of the pooled logistic regressions showed
that the main predictor variables for sexual activity
were being married, having more education, being
younger and being male, with good social networks.
The main predictors for sexual satisfaction (besides
being sexually active) were being female, having
good mental health, and better functional status. In
Vol. 37, No. 1,1997
13
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Received November 15, 1994
Accepted December 13, 1995
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The Gerontologist