7 Old age psychiatry7.11 Psychosexual health in older people
7.11 Sexuality and psychosexual disorders in old age
7 min read2 figures
Written by Resident Doctor Committee · Published
Sexual activity in later life
In the 2012 to 2013 English Longitudinal Study of Ageing, 54% of men and 31% of women over 70 reported sexual activity in the previous year.
Age group | Men active in past year | Women active in past year |
|---|---|---|
70 to 79 | 59.3% | 34.3% |
80 and over | 31.1% | 14.2% |
Partner availability partly explains the sex difference, and inactivity does not mean lack of desire.
Illness, disability and care home routines can restrict intimacy without removing the wish for it.
Care Quality Commission and nursing guidance cover relationships, identity, appearance, sensuality and privacy as well as sexual activity.
Normal ageing and where dysfunction begins
Sex | Normal ageing change | Needs assessment |
|---|---|---|
Men | Slower, less firm erections needing more direct stimulation; less ejaculatory volume and force; longer refractory period | Persistent difficulty achieving the erection needed for wanted activity |
Women | Falling oestrogen thins and dries vulvovaginal tissue and reduces lubrication | Bleeding, which is not put down to atrophy automatically |
Erectile dysfunction may precede symptomatic vascular disease, so check blood pressure, glucose, lipids and cardiovascular risk rather than blaming age.
Genitourinary syndrome of menopause comprises dryness, burning, painful sex, urinary urgency and recurrent infection.
Women are offered lubricants and moisturisers, with local vaginal oestrogen considered; symptoms often recur when they stop.
The National Institute for Health and Care Excellence supports considering testosterone for menopause-associated low desire when hormone replacement therapy alone fails; this is off-label in the UK.
Physical illness
Condition | How it affects sex | What helps |
|---|---|---|
Diabetes | Vascular and autonomic effects on erection, lubrication and ejaculation | Treat diabetes and vascular risks |
Atherosclerosis, hypertension | Reduced genital blood flow | Cardiovascular treatment |
Hypogonadism, thyroid disease | Low desire or arousal with systemic symptoms | Hormonal assessment |
Parkinson's disease | Motor and autonomic problems, fatigue, mood, drug effects | Time activity around motor treatment; review dopamine agonists |
Stroke | Weakness, sensory change, communication difficulty, fear | Safety advice, positioning, communication support |
Spinal disease, cauda equina, peripheral neuropathy | Altered reflexes or sensation | Neurological assessment |
Arthritis, chronic pain | Restricted movement and discomfort | Pain treatment, comfortable positions |
Cardiac, respiratory disease | Exertional limitation, orthopnoea, anxiety | Assess exercise tolerance |
Prostate or pelvic surgery, radiotherapy | Nerve injury, tissue change, incontinence | Urology or gynaecology input, continence care |
After cardiac illness, advice on returning to sex is individual: a comparison with climbing stairs does not replace assessment of unstable symptoms.
Medicines and substances
Ask directly and record baseline sexual function before prescribing psychotropics. A temporal link suggests a drug effect but does not exclude illness or relationship factors.
Drug group | Examples | Mechanism | Point to remember |
|---|---|---|---|
Selective serotonin reuptake inhibitors, serotonin and noradrenaline reuptake inhibitors | All | Serotonergic effects on desire, arousal, orgasm | Delayed or absent orgasm is common; ask rather than wait |
Antidepressants with lower sexual burden | Mirtazapine, bupropion, agomelatine, moclobemide, vortioxetine | Differing receptor effects | Weigh the whole treatment profile |
Prolactin-raising antipsychotics | Risperidone, paliperidone, amisulpride, sulpiride, haloperidol | D2 blockade raises prolactin and may suppress gonadal function | Ask about galactorrhoea; consider bone health |
Antipsychotics with lower prolactin liability | Aripiprazole, quetiapine, clozapine, brexpiprazole, cariprazine, lurasidone | Less prolactin rise | Lurasidone can raise prolactin; low prolactin does not guarantee normal function |
Alpha-1 blockers | Risperidone, chlorpromazine, trazodone, doxazosin | Peripheral adrenergic effects | Erectile or ejaculatory problems; priapism needs emergency care |
Anticholinergics | Oxybutynin, tricyclics, hyoscine, procyclidine | Impaired autonomic response | Total burden also risks delirium, retention, falls |
Antiandrogens | Finasteride, dutasteride, cyproterone, gonadotrophin-releasing hormone analogues | Reduced androgen activity | Finasteride and dutasteride warnings include psychiatric and possibly persistent sexual effects |
Opioids | All | Suppress the hypothalamic-pituitary-gonadal axis | Consider hypogonadism with low desire and fatigue |
Alcohol | None | Acute impairment; chronic neurological, hepatic, gonadal effects | Older people may be more sensitive to a given intake |
Thiazide diuretics | Thiazide-like drugs too | Uncertain | Some trials report more erectile difficulty |
Beta-blockers | None | Effects vary | Do not assume a class-wide causal effect |
Small beta-blocker studies show that expectation shapes reported side effects, so explain risks neutrally without withholding information.
Psychological and relationship factors
Bereavement can bring guilt about new relationships and family objections.
Surgery, stomas, tremor, incontinence or altered appearance can erode confidence; practical continence and positioning advice helps.
Depression reduces desire, and its treatment may add difficulty.
Performance anxiety shifts attention from sensation to monitoring and reinforces failure.
A shift from partner to carer can alter intimacy, but do not assume the relationship has ended.
Assessment without assumptions
Ask who matters to the person and whether they want to discuss intimacy; do not assume heterosexuality, a living partner or penetrative sex.
Older LGBTQ+ people (lesbian, gay, bisexual, trans and queer) may have faced criminalisation or harmful treatment and fear disclosure in care settings.
Explain confidentiality, use inclusive records, and continue organ-based screening and hormone care for trans people.
Assess onset and situations, physical health, medicines, substances, mood, cognition and goals, including whether activity is wanted, whether anyone applies pressure and whether capacity needs assessment.
Treatment
Treat pain, depression, endocrine disease, infection and menopausal symptoms, and review drug effects before adding treatment, balancing change against relapse risk.
Phosphodiesterase type 5 inhibitors can help suitable older men but treat erection, not low desire.
They interact dangerously with nitrates, nicorandil and riociguat; recent major cardiovascular events, unstable angina or significant hypotension need medical assessment first.
Adapt psychosexual work for mobility and pain, and refer to specialist services: age alone should not restrict access.
Capacity to consent to sexual relations
In England and Wales, capacity is presumed and support is given. Incapacity needs an impairment or disturbance of mind or brain causing inability to understand, retain, use or weigh relevant information, or to communicate the decision.
Section 27 of the Mental Capacity Act excludes consent to sexual relations from best-interests decisions: no relative, attorney, deputy or court can consent for the person.
A Local Authority v JB (2021): the Supreme Court held that relevant information includes the other person's ability and continuing agreement to participate, which matters when the person initiates sex.
The person needs a basic, not expert, understanding of the nature of the act, that either person can refuse or withdraw, and pregnancy and infection risks.
Do not test whether the partner is a wise choice or whether the person could parent.
Neither marriage nor apparent compliance establishes consent, and dementia or delirium can change capacity, so reassess when needed.
Scotland uses the Sexual Offences (Scotland) Act 2009; Northern Ireland has separate law, so do not transplant the English test.
Sexual offences and care settings
The Sexual Offences Act 2003 applies in England and Wales.
Sections | Offences | Capacity requirement |
|---|---|---|
30 to 33 | Mental disorder impedes choice | Inability to refuse because of the disorder |
38 to 41 | Care worker offences against a person with mental disorder | Apply despite capacity and apparent agreement |
Spouse, civil partner and pre-existing relationship exceptions need legal advice; Scotland has a separate abuse of trust offence.
Blanket bans on relationships can be disproportionate, while absent boundaries expose residents to harm; use individual assessment, relationships policies, training and safeguarding procedures.
When one partner has dementia
If capacity for sexual activity is absent, it cannot lawfully proceed on anyone else's consent, though other wanted closeness may continue.
The Court of Protection can decide capacity but cannot consent to sex for the person.
Behaviour alone does not bypass the law, so attend to signs of willingness, reluctance or distress.
In a new relationship between residents, assess each separately: cognitive impairment does not mean incapacity, family objections do not override capacitous choices, and neither person is presumed the perpetrator.
Sexual disinhibition
Describe the behaviour and context before labelling it. Estimates in dementia range from about 2 to 17%.
Cause | Distinguishing features | First action |
|---|---|---|
Delirium | Acute fluctuation, inattention, altered arousal | Find and treat causes |
Mania | Mood change, less sleep, pressured speech | Treat the episode |
Behavioural variant frontotemporal dementia | Other behavioural or executive changes | Environmental and behavioural support |
Dopamine agonist impulse control disorder in Parkinson's disease | New compulsive sexual behaviour, sometimes gambling or shopping | Gradual medication review with neurology |
Local physical discomfort | Touching linked to infection, retention, skin irritation, constipation | Treat physical needs |
Disorientation | Misidentification, entering the wrong room or bed | Redirect, protect others |
Unmet need for intimacy | No private space or meaningful activity | Provide privacy and occupation |
Private masturbation is not inherently pathological.
For unwanted behaviour, record antecedents, behaviour and consequences, and use consistent redirection; a neurological cause does not remove safeguarding needs.
Restrictive clothing needs a proportionate legal and care assessment.
No drug is licensed for dementia disinhibition: an SSRI is sometimes tried after other measures, and antipsychotics need a compelling indication given stroke and mortality risk.
Cyproterone and some triptorelin products have restricted indications for reducing male sexual drive, not a general licence for dementia disinhibition; cyproterone carries meningioma risk, and androgen suppression threatens bone.
Surgically implanted hormones to reduce male sexual drive fall under section 57 safeguards: valid consent plus independent certification.
Document the indication, legal basis, target, monitoring and withdrawal plan.