Contemporary Family Therapy (2022) 44:373–380

https://doi.org/10.1007/s10591-021-09589-3

ORIGINAL PAPER

Sexuality of Aging Adults: A Case Study Using Narrative Therapy

Janette J. Driscoll1 · Anthony A. Hughes1

Accepted: 3 June 2021 / Published online: 10 June 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
For those who experience sexual desire, sexuality and sexual expression are a vital part of their emotional well-being at every
age. Prevailing discourses have created an ageist mentality against older people maintaining a sexual identity. The research
states that older people who identify as sexual continue to desire, long for, and enjoy a variety of sexual activities, despite
and sometimes because of increasing physical health concerns. In sex therapy, older clients that examine their dominant
discourses and find that they desire a change that is more sex positive can become sexually empowered through a narra-
tive approach. This article includes a review of the current literature and clinical practices which can enhance therapeutic
outcomes for older couples and individuals who identify as sexual and desire sexual improvement. A case study example
is included as well.

Keywords Aging · Couple therapy · Elderly · Female sexuality · Gerontology · Male sexuality · Narrative therapy · Sex
therapy · Sexuality

The World Health Organization defines sexuality as encom-
passing “sex, gender identities and roles, sexual orientation,
eroticism, pleasure, intimacy and reproduction…experi-
enced and expressed in thoughts, fantasies, desires, beliefs,
attitudes, values, behaviours, practices, roles and relation-
ships” (Defining Sexual Health, n.d.). Sexual identities
appear on a spectrum from asexual (experiencing no sexual
attraction) to allosexual (feeling sexual attraction to others,
with identities including, but not limited to homosexual,
bisexual, pansexual, and heterosexual), including demisex-
ual (experiencing sexual attraction after an intimate bond is
formed), graysexual (only rarely experiencing sexual attrac-
tion), and other identities (Cowan & LeBlanc, 2018; Hille
et al., 2020). This article focuses on aging individuals who
are sexual and want to improve their experience or make
sexuality a more dominant aspect of their lives.
There is a large portion of people who find sexual expres-
sion to be vital to their emotional well-being and couple
satisfaction throughout their life (Bouman et al., 2006;
* Janette J. Driscoll
jjorg1@byu.edu
Anthony A. Hughes
anthony_hughes@byu.edu
1
Brigham Young University, 234 John Taylor Building,
Provo, UT 84602, USA
DeLamater, 2012; Nicolosi et al., 2006). Studies have
repeatedly shown that many older adults prioritize sexual
activity (Dominguez & Barbagallo, 2016) and engage in a
variety of sexual activities including sexual or affectionate
touch, kissing, masturbation or other external stimulation,
and intercourse for heterosexual couples (Bretschneider &
McCoy, 1988; Galinsky, 2012).
The dominant discourse of Western society can unfortu-
nately lead older people to believe that they cannot or should
not experience sexual fulfillment (Laumann & Waite, 2008;
Weeks, 2002). This discourse can be traced to systemic
de-sexualization of elderly individuals by those in power
who neglect to address or discuss sexuality as one of the
vital aspects of personhood. Lack of childhood sexual edu-
cation for the now older generation has been balanced in
part by internet material frequently perused by older adults
to enhance their sexuality (Adams et al., 2003). In addi-
tion, the increasing fixation by popular culture on having
a younger body as key to sexual fulfillment (Bauer et al.,
2007; Gewirtz-Meydan et al., 2019) helps explain how this
de-sexualization has come to pass. Within the trend of de-
sexualization, research appears to show differences by gen-
der (Lindau et al., 2007), sexual identity (Bauer et al., 2007),
and cohort (Beckman et al., 2008).
The systemic de-sexualization of older people has
also leaked into the healthcare sphere (Bauer et al., 2007;

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Gewirtz-Meydan et al., 2019). This could be considered
problematic, given the increase in healthcare utilization most
people require with age (Cheng et al., 2020). If healthcare
providers are ill-equipped to address their older patients’
sexuality due to lack of education, feelings of discomfort, or
other reasons informed by the dominant discourse, they are
inhibited in providing the comprehensive care elderly people
need and deserve (Gewirtz-Meydan et al., 2019).
In therapy, a narrative approach can help deconstruct the
dominant discourse within any culture, although this article
focuses specifically on Western cultural applications. The
authors note that cultural application can look vastly differ-
ent within various cultures and even within a broad cultural
category such as “Western culture.” The process of engaging
in narrative therapy can strengthen the couple relationship,
if applicable, and each individual within their own sexuality
(Muruthi et al., 2018). Therapy provides a place for couples
and individuals to externalize their problems and construct
new, less problem-saturated narratives, independently, as a
couple, or both. As older adults create new narratives to
reduce these impediments on their sexuality, the research
suggests that they will find increased fulfillment and empow-
erment in their sexuality. This article focuses on using nar-
rative therapy to treat aging individuals who are sexual and
want to improve their experience individually or within a
couple relationship.
Literature Review
In the Western discourse, there is an unspoken assumption
that as people age, they become asexual (Risen, 2010). This
may be due to the decline in functionality that bodies gener-
ally experience with age, including in their sexual anatomy
(Lindau et al., 2007). Not only have these narratives been
internalized by the general public, but the elderly them-
selves operate under these facetious narratives, decreasing
their self-esteem and understanding of their own sexuality
(Weeks, 2002).
Despite the prevailing narrative that older people are less
sexual than younger age groups, cohort studies show signifi-
cant differences in sexuality between generations. Experi-
encing different time periods such as the Great Depression or
the sexual revolution during their young adult years appears
to have an effect on the attitudes today’s older generations
have towards sexuality (DeLamater, 2012). To illustrate, a
30-year cross sectional survey found 70-year-old adults in
the year 2000 to be significantly more sexually active (in
terms of intercourse only), satisfied, and positively sexually
oriented than the 1971 cohort of septuagenarians (Beckman
et al., 2008). Some research speculates that future genera-
tions of older people will continue to be more liberal and sex
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Contemporary Family Therapy (2022) 44:373–380
positive as a result of the shifts in sociocultural narratives
during their life (DeLamater, 2012).
Ageism
The dominant discourse that asexuality develops with age
could be considered evidence of an ageist society which
stipulates who can and cannot be sexual (Bauer et al., 2007).
Ageism, or “the discrimination against individuals based on
their age” invites a narrative that older people are unable to
be sexual, adventurous, or erotic (Angus & Reeve, 2006, p.
138). At its core, however, many people consider sex to be
an important contributor to quality of life because of their
association between sex, love, and affection (Nicolosi et al.,
2006). When mainstream ideology taboos sexuality for
aging adults, it could by extension be suggesting that aging
adults are incapable or undeserving of love and affection that
can come through a sexual relationship.
Sexism
Attitudes towards sex can be informed by societal narratives,
some of which may be considered problematic. For example,
older men stereotypically present as more charming, flirta-
tious, and desirable than older women (Lindau et al., 2007;
Waite et al., 2017). Women, conversely, frequently attempt
to cover their gray hair, looser skin, and other natural evi-
dence of aging due to the negative social consequences they
expect to experience with appearing older (Ward & Holland,
2011). According to Waite et al. (2009), men tend to hold
more positive views of sexuality and sexual expression than
women, regardless of age. It is possible that because sex
is more acceptable and accessible to men within dominant
social narratives, they feel more positively towards sexuality,
while women have more barriers to exploring and embracing
their own sexuality.
Sexual Minorities
Discourses around sexual activities for older people, though
few, are limited to male-dominated, hetero-centric sexual
encounters (Dominguez & Barbagallo, 2016). This encour-
ages the assumption that all elderly people are heterosexual,
if they are sexual at all, which is untrue and marginalizes
those who are not heterosexual (Bauer et al., 2007). In a
2011 report on the well-being of aging lesbian, gay, bisex-
ual, and transgender (LGBT) adults, 55 percent of those
surveyed reported having been sexually active within the
past year (Fredriksen-Goldsen et al., 2011). There are an
estimated one to three million lesbian and gay adults over
60 in America (Agronin, 2014). These individuals have
Contemporary Family Therapy (2022) 44:373–380
spent much of their lives constructing a positive sense of
self amidst severe oppression and lack of support (Morrow,
2001), and they are again marginalized within the already
marginalized demographic of sexually active older adults
(Laumann & Waite, 2008). Assuming that the elderly are
heterosexual leads to desexualization and increased diffi-
culty for LGBTQ + persons to foster healthy sexuality. The
same assumption may also lead to sexual health concerns for
the older population because of unaddressed biases held by
medical care providers.
Common Difficulties with Sexual Expression
As in younger couples, sexual satisfaction and marital satis-
faction are closely linked in aging couples (Meston, 1997).
Older couples may experience a gradual decline in sexual
interest in one or both partners, which can create feelings
of discontent and lead the couple to seek help (Bitzer et al.,
2008). Older couples also seek sex therapy after a major
life stressor, such as the loss of a loved one, chronic illness,
or hospitalization, which can dampen relationship function-
ing and satisfaction (Agronin, 2014). Other research found
that dissatisfaction within an aging couple’s sexual relation-
ship is linked to feelings of obligation, balance of initiation,
and decreased sexual functioning (Lee et al., 2016). Weeks
(2002) asserts that the primary psychosexual problems of
older individuals stem from couple dynamics, including lack
of tenderness, low physical contact, and feelings of loneli-
ness, rather than their age or biological changes. Clinicians
may benefit from considering the couple relationship as a
main framework for understanding aging clients’ sexual
experiences, along with each client’s individual factors
(Hertlein et al., 2015).
Female Presenting Problems
Women young and old commonly experience three main
problems in relation to their sexual functioning: low desire,
insufficient vaginal lubrication, and inability to climax
(Lee et al., 2016; Lindau et al., 2007). As women age, their
frequency of sexual activity decreases, due in part to poor
health which tends to affect women more so than men (Lau-
mann & Waite, 2008). Some research indicates a sharp
decline for females in solo and partnered sexual activity as
they age (Herbenick et al., 2010). Although distress over
sexual problems appears to peak during middle age, the
increasing number of physical and sexual problems with age
leads many to seek treatment (Shifren et al., 2008).
Male Presenting Problems
The leading sexual problems for men beginning in their
late fifties are erectile difficulties (37%; Lee et al., 2016;
375
Lindau et al., 2007). Although it may not be a direct cause,
decreased penile sensitivity with age can contribute to
these difficulties (Perelman, 2014). Older men are also
prone to experience low desire for several reasons, includ-
ing medications such as SSRIs and health concerns such
as cardiovascular disease, cancer, depression, and anxiety,
to name a few (Hertlein et al., 2015).
Gender Differences in Sexual Expression
Some research suggests that men find sexually satisfying
relationships more integral to their quality of life than
do women (Bretschneider & McCoy, 1988; DeLamater,
2012). Men of all ages report sexual activity, interest
in sex, and a high-quality sex life more frequently than
women (Lindau et al., 2007). In the Lindau et al. (2007)
study, the differences between genders were most pro-
nounced in the 75 to 85-year-old age group. In this group,
over 20 percent more men than women reported being
sexually active, and 20 percent more men than women of
those who were sexually active reported having a good
quality sex life (Lindau et al., 2007). The gender differ-
ences shown here may be explained by physical health
problems, women outliving their male partners, and the
relative normalcy of older men partnering with younger
women compared to older women partnering with younger
men (Herbenick et al., 2010; Waite et al., 2017).
Physiological Manifestations of Age
Physical health is another key component of sexual func-
tioning which impacts both women and men (Lee et al.,
2016). Although physical health concerns tend to increase
with age, many of advanced age still experience fulfilling
sexual relationships (Lee et al., 2016; Lindau et al., 2007).
Current research confirms that anatomical functionality is
neither necessary nor sufficient for fulfilling sexual activity
(Kleinplatz, 2010). Some research suggests that women are
more affected by poor health than men; however, all peo-
ple experience its effects on their sexual lives (Laumann
& Waite, 2008). Cardiovascular disease, cancer, diabetes,
and arthritis, along with their accompanying treatments, can
negatively impact sexual functioning (Bauer et al., 2007).
Certain medications have also been shown to impede sexual
processes (Bauer et al., 2007). Anxiety rises as older peo-
ple consider the possibility of having a heart attack during
sexual activity, especially if they have a relevant history or
pre-existing condition (Johnson, 2004). Surgical procedures,
such as a hysterectomy in women, can also impose physical
pain, changes to the sexual response cycle, and weakened
body image, all of which can affect their sexual experience
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376
(Forsgren & Altman, 2013; Meston, 1997). In short, sex-
ual desire often decreases when the body feels unwell, and
instances of feeling unwell tend to increase with age for both
women and men.
Female Physiology
As the effects of menopause settle into the female body, both
the appearance and functioning of the genitalia change signifi-
cantly. Some pertinent changes include decreased blood flow
to the genitals, delayed and reduced vaginal lubrication, thin-
ning of vaginal walls, and less intense orgasmic experiences
(Meston, 1997). Dyspareunia or pelvic pain with intercourse
is a common sexual complaint among older women and can
be explained by the physical changes just described (Meston,
1997). Often, these changes lead to lower desire; however,
plenty of post-menopausal women report an increase in desire
(Meston, 1997; Rabiee et al., 2015). A recent study on slightly
younger women (age 45–60) in the process of menopause
showed that only about 35% of participants reported a lower
sexual desire than what they experienced before menopause
(Rabiee et al., 2015).
Male Physiology
A common misconception about male sexual development is
that testosterone should remain relatively stable over time. In
fact, testosterone does remain stable until around age 50, after
which it gradually decreases (Meston, 1997). Although impo-
tence, lower libido, and longer refractory periods are often
attributed to testosterone alone, these changes are all natural
and integral to the aging process (Meston, 1997). For men as
well as women, medications, mental health conditions, and
chronic health problems are only some of the factors at play
in continued sexual development (Corona et al., 2010). Like
females, aging males also exhibit declines in solo and part-
nered sexual activity, although the declines are not as dramatic
(Herbenick et al., 2010). Health factors, medications, and
changes in anatomical functioning contribute to this decline
for both men and women.
As life expectancy increases, we should expect the sexu-
ality of aging people to become more widely accepted and
understood (DeLamater, 2012). Many older couples report
becoming more in tune with their sexual preferences and feel-
ing more comfortable expressing them over time, despite the
negative stereotypes they face (Lee et al., 2016). This literature
would suggest that ageism in sexuality could be damaging and
negate the fulfillment that many couples and individuals find
in sexual expression. Additionally, extant literature highlights
the benefits of accepting and encouraging sexual activity as
part of a healthy life, even into the later years.
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Contemporary Family Therapy (2022) 44:373–380
Clinical Skills
Facilitating Collaboration with Physicians
Older people often shy away from talking about sex with
their doctors, despite the connection between their health
and sexual functioning which grows over time (Lindau et al.,
2007). Likewise, medical professionals frequently avoid
the topic of sex with their older patients due to feelings of
embarrassment or awkwardness, implicit assumption that
their patient has become asexual, or lack of education on
sexuality in later life (Brandenburg & Bitzer, 2009; Gewirtz-
Meydan et al., 2019). Some physicians have even told their
older patients they should be grateful to simply be alive and
be less concerned about their sexual needs being met (Risen,
2010). Both physicians and older adults could prioritize the
sexual needs of the patient through increased education and
openness (Laumann & Waite, 2008).
Narrative Therapy
Narrative therapy is built on the idea that meaning is co-
constructed and can be changed through deconstruction and
re-storying (Muruthi et al., 2018). Meaning is constructed in
part from scripts, which reflect internalized value systems
and experiences (Gagnon & Simon, 1973). “Scripts oper-
ate at a social, personal, and intrapsychic level. They are
embedded in social institutions and as such are internalized
by individuals” (Atwood & Dershowitz, 1992, p. 201). A
narrative approach allows for a judgment-free exploration
and adjustment of internalized scripts in order to help clients
make their own meaning of their lives (White & Epston,
1990). Using narrative therapy in sex therapy with aging
clients allows them the freedom to question, explore, and
refine their value systems and the meaning they make of
their evolving sexual experience.
Expectations Couples should be educated on normative
sexual changes in aging bodies and relationships, especially
including changes in testosterone which are often portrayed
in the media as needing medical intervention (Hertlein
et al., 2015). The functionality of sexual organs does not
guarantee nor preclude positive sexual encounters (Klein-
platz, 2010). Couples should also develop flexibility with
their definition of sexual intimacy, including the amount of
effort their interactions will require. Kleinplatz (2010) sug-
gests that clients remember the effort they expended early in
their relationship and practice implementing that same level
of effort again. The therapist should provide opportunities
for dialogue and for the clients to ask questions about what
is being presented (White & Epston, 1990).
With the understanding that each sexual relationship
develops differently, the therapist should expect the couple
Contemporary Family Therapy (2022) 44:373–380
to discover their unique hopes and abilities in regard to sex.
Some elderly people choose not to have sexual intercourse
after a certain point, choosing instead to focus on emo-
tional or other types of intimacy (Bauer et al., 2007). Cou-
ples should also explore expressions of physical closeness
beyond vaginal intercourse, especially as they will likely
need to adapt to changes in desire, arousal, or physical func-
tioning (McCabe et al., 2016; McPhillips et al., 2001).
Validation It is natural for people experiencing sexual dys-
function to feel disappointed and even defective, which
can lead to low desire (Kleinplatz, 2010). Elderly people
may be embarrassed to admit they still have needs for sex-
ual closeness and gratification because of the social taboo
on the topic (Risen, 2010). Normalizing this experience for
older clients may sound like, “If I had the kind of sex you’ve
been having, I wouldn’t want it either” (Kleinplatz, 2010,
p. 67). Providing validation throughout the course of treat-
ment is integral to the clients’ feelings of safety, normalcy,
and hope.
Other Interventions Treating older adults in sex therapy is
much like treating clients of any age with a specific diagno-
sis. Keeping in mind the contextual factors described in the
literature review, clinicians can modify their interventions
to be approachable to the older client. Kleinplatz (2010) rec-
ommends beginning by redefining sex, given that sociocul-
tural norms often limit the definition to intercourse alone.
Another intervention recommended by Kleinplatz (2010) is
to invite each partner to write three fantasies or memories
of the couple’s sexual relationship and discuss their lists in
session. Many, but not all older couples have a sexual his-
tory that spans decades, and reminiscing on their history
can provide a unique opportunity for growth which younger
couples do not yet have.
Following is a case study example in which an elderly
couple engaged in sex therapy with a narrative approach.
Case Study: Constructing a New Narrative
of an Elderly Couple’s Sexuality
Susan and Dale, a retired couple in their early-70’s who had
been married for 50 years presented for sex therapy after
dealing with desire and satisfaction discrepancies off and on
beginning about five years into their marriage. Susan expe-
rienced low sexual desire, which led to low couple sexual
satisfaction and overall lower relationship satisfaction for
both partners. The couple was Caucasian, middle-class,
of a Christian faith, and a first marriage for both partners.
They had four children who all lived in their own homes,
two in-state and two out-of-state. They also had several
377
grandchildren and were active in all their children and
grandchildren’s lives.
The clients were referred by another therapist with whom
they had done individual and couple work, including sex
therapy, for over a year and who felt they would benefit from
more intensive treatment. Both Dale and Susan were very
invested in therapy; however, it became clear that they were
working to meet a societally imposed, male-centric narrative
of sexuality that was conflicting for Susan. She defaulted to
identified patient-hood with the previous therapist, which
inhibited the couple’s progress.
Susan reported feeling throughout the marriage that her
concerns about the couple’s sexual relationship were dif-
ferent than Dale’s. Susan reported no trouble orgasming
and that for her, orgasm was not the top priority. She and
Dale also began to think that she was not as sexual as other
women they had heard about and what they had assumed
from mainstream narratives. Beginning about five to six
years into the marriage, the couple negotiated different types
of sexual contracts concerning frequency and tried various
strategies to fit Susan’s sexual desires to societal scripts they
had internalized. Some years were better than others, but
she never felt that she was sexually okay or valid. In fact,
she discovered in therapy that her sexuality had been either
discounted or not seen by either of them since it was outside
the mainstream societal scripts.
Therapy Implications
Given the couple’s age, there were several factors to con-
sider throughout their treatment. First and foremost, their
upbringing in an era without the internet or accessible sex
education had an impact on the couple’s development of
discourses around sex and therefore their own sexuality.
Other narratives may have presented in the form of cultural
and religious sexual teachings, especially during the years
of sexual development. Social and relational factors could
have impacted openness around sexual communication; the
couple described their generation as being closed to sexual
communication. Since the couple had been together for over
50 years, the therapist also considered fixed or rigid rela-
tionship patterns and assumptions, including problematic
assumptions about each other that may have been enforced
throughout the marriage. The same can be said about indi-
vidual self-concept and adaptability, which could possibly
have become less flexible over time. Finally, the therapist
assessed for and considered biological and physiological
factors such as the impact of age on vital sexual systems
and functioning.
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Intervention: Intersystemic Assessment
The therapist completed a thorough assessment with
intersystemic sex therapy. This helped to unearth Susan’s
sexual template. There were multiple elements that were
discounted and not written into her personal narrative or
the narrative about her that pointed to her being a very
sexual being. However, for most of her life Susan had seen
herself as non-sexual since her experiences did not fit rigid
scripts provided by society, her upbringing, the media,
and what she had heard from others. Compared to those
scripts, Susan considered herself to be sexually repressed
and inhibited.
Intervention: Re‑storying the Narrative
Throughout therapy, Susan was encouraged to examine
and redefine narratives she held about herself and her
sexuality. She came to realize that she had been a sexual
being for years without knowing it. One example of this
took place over 50 years prior, when the couple was dat-
ing. On a trip to the lake, while boating, Susan removed
her bathing suit top. She reported feeling liberated, sexy,
“naughty”, a tease, and attractive. All these feelings were
more interesting and arousing to her than orgasm or inter-
course. However, once the couple became sexually active,
feeling liberated, sexy, or “naughty” often gave way to
accomplishing intercourse and orgasm. This caused Susan
to think that she was not a strong sexual being and ulti-
mately inhibited her sexuality from flourishing. As she
took inventory of who she was related to sexuality, Susan
always neglected to include these “naughty” situations
rather than incorporating them into her narrative and see-
ing them as valid and highly erotic for her. She reported
that feeling sexy by removing her swimsuit top was liber-
ating at the time but that she did not understand why until
therapy five decades later.
After re-writing her narrative, Susan began expressing her
sexuality more freely without specific direction from anyone.
For example, she would choose not to wear a bra when the
couple went out for dinner or not to wear any underwear on
a car ride, inviting her husband to touch her while they were
driving. Susan reported that although Dale seemed not to
find this as arousing as their usual sexual encounters, these
activities helped her to feel increased arousal, desire, and
sexual in their own right. In reconstructing her personal nar-
rative, Susan chose to give orgasms less weight, despite the
ease of experience, and instead focused on finding what was
arousing for her, individually. She could see that she was in
fact more sexual as someone that longed for and participated
in these new “naughty” situations than having intercourse
or orgasm. Together, the couple began to see the problems
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Contemporary Family Therapy (2022) 44:373–380
with adopting societal sexual scripts without modification
for their unique lives and circumstances. Dale was able to
dispel some of the sexual myths he had held, including the
ideas of a hierarchy of sexual activities, a stepwise progres-
sion in sexual encounters, and requirements of orgasm and
intercourse for sex to be considered fulfilling. Dale’s broad-
ened narrative led to him accepting his wife’s sexuality as
well. The couple also began to see that “success” was not
defined by the strict outcome of orgasm and intercourse,
which had been their adopted mindset for so many years.
Clients’ Receptivity to Intervention
Throughout the re-storying process, there was some ambiva-
lence from the system, as they had been given messages that
sexuality looks a certain way. There was also ambivalence
in the system as they and other systems, including their past
therapist and cultural influences, viewed the wife as the
identified patient, rather than the couple system and large
societal and cultural systems needing attention in treatment.
In other words, the couple’s problems could be considered a
symptom of the larger society that limits sexuality into a nar-
row box. As a result, feedback loops get sent back into the
couple systems and larger societal systems to reinforce rigid
and unhealthy scripts. The couple was able to work through
this ambivalence and systemic sexual scripting and become
more open to what their own sexuality meant for them.
Conclusion
Sexual satisfaction is a significant contributor to relationship
satisfaction, if a relationship is present, and overall well-
being in many older people. Although health deterioration,
endocrine changes, and pharmacological effects can affect
sexual functioning for both women and men, this does not
render them unable to experience the pleasure, connection,
and fulfillment that come with sexual activity. Address-
ing the dominant discourses, physical changes, and couple
dynamics present in each aging client’s story will enable the
client and therapist to facilitate a healthy, lasting relationship
with sexuality.
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