Composite case studies have been selected to identify and illustrate the dysfunctional characteristics of the male aging process.

Both Mr. and Mrs. A were 66 and 62 years of age when referred to the Foundation for sexual inadequacy. They had been married 39 years and had three children, the youngest of whom was 23 years of age. All children were married and living outside the home.

They had maintained reasonably effective sexual interchange during their marriage.

Mr. A had no difficulty with erection, reasonable ejaculatory control, and, aside from two occasions of prostitute exposure, had been fully committed to the marriage. Mrs. A occasionally orgasmic during intercourse and regularly orgasmic during her occasional masturbatory experiences had continued regularity of coital exposure with her husband until five years before referral for therapy.

Mr. A had recently retired from a major manufacturing concern. He had been relatively successful in his work and there were no specific financial problems facing man and wife during their declining years.

Both members of the marital unit had enjoyed good health throughout the marriage. At age 61, he had taken his wife abroad on a vacation trip which entailed many sightseeing trips with a different city on the agenda almost every day.

They were chronically tired during the exhausting trip, but because they were on vacation and away from home there was a definite increase over the established frequency of coital connections. Mr. A noted for the first time slowed erective attainment.

Regardless of his level of sexual interest or the depth of his wife’s commitment to the specific sexual experience, it took him progressively longer to attain a full erection. With each sexual exposure his concern for the delay in erective security increased until finally, just before termination of the vacation trip, he failed for the first time to achieve an erection quality sufficient for vaginal penetration.

When the coital opportunity first developed after return home, erection was attained, but again it was quite slow in development. The next two opportunities were only partially successful from an erective point of view, and thereafter he was secondarily impotent.

After several months they consulted their physician and were assured that this loss of erective power comes to all men as they age and that there was nothing to be done. Loath to accept the verdict, they tried on several occasions to force an erection with no success. Mr. A was seriously depressed for several months but recovered without apparent incident.

Approximately 18 months after the vacation trip, the couple had accepted their “fate.” The impotence was acknowledged to be a natural result of the aging process. This resigned attitude lasted approximately four years.

Although initially the marital unit and their physician had fallen into the socio-cultural trap of accepting the concept of sexual inadequacy as an aging phenomenon, the more Mr. and Mrs. A considered their dysfunction the less willing they were to accept the blanket concept that lack of erective security was purely the result of the aging process.

They reasoned that they were in good health, had no basic concerns as a marital unit, and took good care of themselves physically. Therefore, why was this dysfunction to be expected simply because some of their friends reportedly had accepted the loss of male erective prowess as a natural occurrence?

Each partner underwent a thorough medical checkup and sought several authoritative opinions, refusing to accept the concept of the irreversibility of their sexual distress. Finally, approximately five years after the onset of a full degree of secondary impotence, they were referred for treatment.

Sexual functioning was reconstituted for this marital unit within the first week after they arrived at the Foundation and as soon as they could absorb and accept the basic material directed toward the variation in the physiological functioning of the aging male.

No longer were they concerned with the delay in erective attainment; there were no more attempts to will, force, or strain to accomplish erection under assumed pressures of performance.

In short:
They needed only the security of the knowledge that the response pattern which initially had raised the basic fear of dysfunction was a perfectly natural result of the involutional process.

When they could accept the fact that it naturally took longer for an older man to achieve an erection, particularly if he were tired or distracted, the basis for their own sexual inadequacy disappeared.

Some six years after termination of the acute phase of therapy, this couple, now in the early seventies and late sixties, continue coital connection once or twice a week.

The husband has learned to ejaculate on his own demand schedule, and neither partner attempts a rapid return to sexual function after a mutually satisfactory sexual episode.

Husband and wife B

The husband, age 62, and his wife, age 63, were referred to the Foundation. They had two children, both of whom were married and lived out of the home.

Their sexual dysfunction had begun when the husband was 57 years old. He had noted some delay in attaining erection and marked reduction in ejaculatory volume and was particularly concerned with the fact that the ejaculatory experience was one of the mere dribbling of seminal fluid from the external urethral meatus, under obviously reduced pressure.

All these involutional signs and symptoms developed within approximately a year after he had noticed some delay in onset of erection attainment.

The more he worried about his symptoms the more frequent the occasions of impotence.

Mrs. B was completely convinced that this pattern of sexual involution was true to be expected as part of the aging process.

Rather than distress her husband, she suggested that they use separate bedrooms.

She changed from a pattern of free and easy exchange of sexual demand to one of availability for coital connection only at her husband’s expression of interest. To resolve her own sexual tensions, she masturbated about once every ten days to two weeks without her husband’s knowledge.

Finally, Mr. B developed severe prostatic spasm with ejaculation during approximately half the increasingly rare occasions when there was sufficient erective security to establish a coital connection. It was the persistence of this symptom of pain that first brought medical consultation and ultimately referral for treatment.

In the evaluation of this man during the physical examination, there was marked muscular weakness noted, a history of easy fatigability, and increasing lassitude in physical expression.

Mr. B also had been distressed in the last two to three years before referral to therapy with distinct memory loss for recent events. He described the loss of work effectiveness for approximately the same length of time.

With these overt symptoms suggestive of steroid starvation, testosterone replacement was initiated empirically. Within those days there was a partial return of ejaculatory pressure and a moderate shortening of the time span for the delayed erective reaction. The prostatic pain did not recur.

Husband and wife B Steroid Replacement

Once Mrs. B could accept the explanation for the onset of her husband’s sexual dysfunction, she was pleased to return to the role of an active sexual partner. The coital connection has continued regularly for the past three years with both members of the marital unit supported by steroid-replacement techniques.

In brief, for the sexually dysfunctional aging male, the primary concern is one of education so that both the man and his wife can understand the natural involutional changes that can develop within their established pattern of sexual performance.

Sex steroid replacement should be employed only if definite physical evidence of the male climacteric exists. As the newer techniques for establishing testosterone levels in blood serum become more widely disseminated, it will be infinitely easier to define and describe the male climacteric and therefore to offer testosterone replacement to those who need it, on a more definitive basis than an empirical diagnosis.

With effective dissemination of information by proper authority, the aging man can be expected to continue in a sexually effective manner into his ninth decade. Fears of performance are engendered by a lack of knowledge of the natural involutional changes in male sexual responsivity that accompany the aging process.

Really, the only factor that the aging male must understand is that loss of erective prowess is not a natural component of aging.

Statistical evaluation of the aging population and a consideration of treatment failure rates will constitute the following section. This material arbitrarily has been placed in the male rather than the female.

First, it was felt important to keep the statistical consideration of the aging marital units together, and second, because there were 56 males So years old or over in marital units accepted for treatment and only 37 wives 50 or older, it seemed appropriate to include the brief statistical discussion in the chapter reflecting the larger segment of the aging population.

Aging Male Sex

The natural aging process creates some specific physiological changes in the male cycle of sexual response. Knowledge of these cycle variations has not been widely disseminated.

There have been little concept of a physiological basis for differentiating between natural sexual involution and pathological dysfunction when considering the problems of male sexual dysfunction in the post-so age group.

If all too few professionals are conversant with anticipated alterations in male sexual functioning created by the aging process, how can the general public be expected to adjust to the internal alarms raised by these naturally occurring phenomena?

Tragically, yet understandably, tens of thousands of men have moved from effective sexual functioning to varying levels of secondary impotence as they age, because they did not understand the natural variants that physiological aging imposes on previously established patterns of sexual functioning.

Sexually Impaired at 50

From a psychosexual point of view, the male over age 50 has to contend with one of the great fallacies of our culture. Every man in this age group is arbitrarily identified by both public and professional alike as sexually impaired.

When the aging male is faced with unexplained yet natural involutional sexual changes and deflated by widespread psychosocial acceptance of the fallacy of sexual incompetence as a natural component of the aging process, is it any wonder that he carries a constantly increasing burden of fear of performance?

Before discussing specifics of sexual dysfunction in the aging population, the natural variants that the aging process imposes on the established male cycle of sexual response should be considered.

For sake of discussion, the four phases of the sexual response cycle excitement, plateau, orgasm, and resolution will be employed to establish a descriptive framework. Also for descriptive purposes, the term older man will be used about the male population from 50 to 70 years of age, and the term younger man used to describe the 20 to 40 year age group.

In recent years the younger man’s sexual response cycle has been established with physiological validity and will serve as a baseline for comparison with the physiological variations of aging.

If an older man can be objective about his reactions to sexual stimuli during the excitement phase, he may note a significant delay in erective attainment compared to his facility of response as a younger man.

Most older men do not establish an erective response to effective sexual stimulation for a matter of minutes, as opposed to a matter of 9f seconds as younger men, and the erection may not be as full or as demanding as that to which previously he has been accustomed.

It simply takes the older man longer to be fully involved subjectively in acceptance and expression of any form of sensate stimulation.

If natural delays in reaction time are appreciated, there will be no panic on the part of either husband or wife. If, however, the aging male is uninformed and not anticipating delayed physiological reactions to sexual stimuli, he may indeed panic and responding in the worst possible way to try to will or force an erection.

The unfortunate results of this approach to erective security have been discussed at length in the treatment of impotence.

Aging Male Erections

As the aging male approaches the plateau phase, his erection usually has been established with fair security. There may be little if any testicular elevation, a negligible amount of scrotal-sac vasocongestion, and minimal deep vascular engorgement of the testes.

Most older men who have had a pre-ejaculatory fluid emission (Cowper’s gland secretory activity) will notice either total absence of, or marked reduction in, the amount of this pre-ejaculatory emission as they age.

From the aspect of time-span, the plateau phase usually lasts longer for an older man than for his younger counterpart. When an aging male reaches that level of elevated sexual tension identified as thoroughly enjoyable, he usually can and frequently does wish to maintain this plateau-phase level of sensual pleasure for an indefinite period of time without becoming enmeshed by ejaculatory demand.

This response pattern is age-related; the younger man tends to drive for early ejaculatory release when plateau-phase levels of sexual tension have accrued. One of the advantages of the aging process with specific reference to sexual functioning is that.

Generally speaking, control of ejaculatory demand in the 50 to 70 year age group is far better than in the 20 to 40 year age group.

In the cycle of sexual response, the largest number of physiological changes to come within an objective focus for older men occurs during the orgasmic phase (ejaculatory process). The orgasmic phase is relatively standardized for younger men, varying minimally in duration and intensity of experience unless influenced by the psychosexual opposites of long-continued continence or a high level of sexual satiation.

For younger men, the entire ejaculatory process is divided into two well-recognized stages. The first stage, ejaculatory inevitability, is a brief period of time (2 to 4 seconds) during which the male feels the ejaculation coming and no longer can control it before ejaculation actually occurs.

These subjective symptoms of ejaculatory inevitability are created physiologically by regularly recurring contractions of the prostate gland and, questionably, the seminal vesicles. Contractions of the prostate begin at o.8-second intervals and continue through both stages of the male orgasmic experience.

The second stage of the orgasmic phenomenon consists of the expulsion of the seminal-fluid bolus accrued under pressure in the membranous and prostatic portions of the urethra, through the full length of the penile urethra.

Again, there are regularly recurring 0.8-second inter-contractile intervals. This specific interval lengthens after the first three or four contractions of the penile urethra in younger men.

Subjectively, the sensation is one of the flows of a volume of warm fluid under pressure and emission of the seminal fluid bolus in ejaculatory spurts with a pressure sufficient to expel fluid content distances of 12 to 24 inches beyond the urethral meatus.

As the male ages, he develops many individual variants on the basic theme of the two-stage orgasmic experience described for the younger man. Usually, his orgasmic experience encompasses a shorter time span.

There may not be even a recognizable first stage to the ejaculatory experience so that an orgasmic experience without the stage of ejaculatory inevitability is quite a common occurrence.

Even with a recognizable first stage, there still may be marked variation in reaction patterns. Occasionally, the older man’s phase of ejaculatory inevitability lasts but a second or two as opposed to the younger man’s pattern ranging from 2 to 4 seconds.

In an older man’s first-stage experience, there may be only one or two contractions of the prostate before involuntary initiation of the second stage, seminal-fluid expulsion.

Alternatively, the first stage of orgasmic experience may be held for as long as 5 to 7 seconds. Occasionally the prostate, instead of contracting within the regularly described pattern of 0.8-second intervals, develops a spastic contraction, creating subjectively the sense of ejaculatory inevitability.

Inadequate Testosterone

The prostate may not relax from spasm into rhythmically expulsive contractions for several seconds, hence the 5-7-second duration of the first-stage experience. In addition to objective variants in a first-stage orgasmic episode, there may be no possible objective or subjective definition of the first stage of orgasmic experience at all.

The stage of ejaculatory inevitability may be totally missing from the aging male’s sexual response cycle. A single-stage orgasmic episode develops clinically in two circumstances.

The first circumstance is that of clinical dysfunction developing as the result of inadequate testosterone production.

Actually, the lack of a recognizable first stage in orgasmic experience can result from a low sex-steroid level for the male just as steroid starvation in the female may produce an orgasmic experience of markedly brief duration.

The second occasion of an absent first stage in the orgasmic experience develops after there has been a prior denial of ejaculatory opportunity over a long period of intravaginal containment to satisfy the aging male’s coital partner sexually.

There also are obvious physiological changes in the second stage of the orgasmic experience that develop with the aging process.

The expulsive contractions of the penile urethra have onset at 0.8second intervals but are maintained for only one or two contractions at this rate:

The expulsive force delivering the seminal fluid bolus externally, so characteristic of second-stage penile contractions in the younger man, also is diminished, with the distance of unencumbered seminal-fluid expulsion ranging from 3 to 12 inches from the urethral meatus.

Arbitrarily, statistics reflecting the failure rates of treatment procedures for sexual dysfunction in the aging population will be considered in this section rather than dividing the material between the discussions of sexual inadequacy in the aging male and female.

A brief single presentation seems in order since only marital units are available for consideration in this age group. The male and female statistics are essentially inseparable from a therapeutic point of view, and the overall sample is entirely too small for definitive individual interpretation.

Statistics

In 51 of the total of 56 aging marital units treated for sexual dysfunction, the husband was the instigating agent in bringing the marital unit to therapy. Among the remaining 5 couples, the referral apparently was by the mutual accord in 3 and only at the demand of the wife in 2 couples.

There also was a higher incidence of referred male sexual dysfunction than of female sexual inadequacy in the aging population. Therefore the discussion will focus on the male partner’s age as a point of departure.

Since the husband was the partner most often involved in dysfunctional pathology and was the member of the unit that usually took the necessary steps to accomplish referral to the Foundation, the aging male will be statistically highlighted.

The 56 marital couples referred for treatment divide into 33 units with bilateral complaints of sexual dysfunction and 23 units with unilateral complaints of sexual inadequacy. Thus, there were 89 individual cases of sexual dysfunction treated from the 56 units with husbands’ age 5o years or over as a common baseline.

This 33:23 ratio is a reversal of the overall statistics for dual-partner involvement of marital units as opposed to singly involved units. The fact that bilateral sexual deficiency was dominant among the older marital units is in accord with previously expressed concepts of cultural influences.

Certainly, the older the marital unit the better chance for the Victorian double standard of sexual functioning. With these pressures of performance, one could almost expect more male than female sexual pathology to be in identified unit partners over 50 years of age referred to the Foundation.

The clinical complaints registered by the aging population (male and female) in the 56 marital units referred for treatment. There was a 30.3 percent failure rate to reverse sexual dysfunction, regardless of whether both partners or a single partner is involved, in any marriage with the husband over 50years of age. With gender separation, for the aging male (50 to 79) there was a 25 percent failure rate to reverse his basic complaint of sexual inadequacy as compared to a 40.7 percent failure rate for the aging female (50 to 79).

These statistics simply support the well-established clinical concept that the longer the specific sexual inadequacy exists, the higher the failure rate for any form of therapeutic endeavor.

On the other hand, there was significantly less than the 50 percent failure rate in treatment for any form of sexual dysfunction, regardless of the age of the individuals involved. In short, even if the sexual distress has existed for 25 years or more, there is every reason to attempt the clinical reversal of the symptomatology.

There is so little to lose and so much to gain. Presuming generally good health for the sexual partners, and mutual interests in reversing their established sexual dysfunction, every marital unit, regardless of the ages of the partners involved, should consider the possibility of clinical therapy for sexual dysfunction in a positive vein. The old concept “I’m too old to change” does not apply to the symptoms of sexual dysfunction.

Probably the most important psychophysiological alteration of sexual patterning to develop during the 50 to 70 year period is the human male’s loss of high levels of ejaculatory demand.

So many men in the older age groups consider themselves too old to function sexually, yet cannot explain how they have arrived at this conclusion.

As the male ages, he not only enjoys a fortuitous increase in ejaculatory control but also has a definite reduction in ejaculatory demand.

For Example:

If a man 60 years of age has intercourse on an average of once or twice a week, his own specific drive to ejaculate might be of the major moment every second or third time there is coital connection.

This level of innate demand does not imply that the man cannot or does not ejaculate more frequently. He can force himself and/or be forced by the female-partner insistence to ejaculate more frequently, but if left to resolve his own individual demand level he may find that an ejaculatory experience every second or third coital connection is completely satisfying personally.

Explicitly his own subjective level of ejaculatory demand does not keep pace with the frequency of his physiological ability to achieve an erection or to maintain this erection with full pleasure on an indefinite basis.

This factor of reduced ejaculatory demand for the aging male is the entire basis for the effective prolongation of sexual functioning in the aging population.

If an aging man does not ejaculate, he can return to an erection rapidly after prior loss of erective security through distraction or female satiation.

The older man can easily achieve and maintain an erection if there is no ejaculatory threat in the immediate offing. The uninformed woman poses an ejaculatory threat. She believes that she has not accomplished a woman’s purpose unless her coital partner ejaculates.

How many women in our culture feel they have fulfilled the feminine role if their partner has not ejaculated? Whether he likes it or needs it, she must be a good sexual partner. “Everybody knows that a man needs to ejaculate every time he has intercourse” and so goes the refrain.

The message should reach both sexes that after members of the marital unit are somewhere in the early or middle fifties, demand for sexual release should be left to the individual partner.

Then coital connection can be instituted regularly and individual male and female sexual interests satisfied. These interests for the woman can range from the demand for multi-orgasmic release to just desiring vaginal, penetration, and holding, without any effort at tension elevation.

If the male is encouraged to ejaculate on his own demand schedule and to have intercourse as it fits both sexual partners’ interest levels, the average marital unit will be capable of functioning sexually well into the 80 year age group, presuming for both man and woman a reasonably good state of general health and an interested and interesting sexual partner.

Effective sexual function for any man in the 50 to 70 year age group depends primarily upon his full understanding of the sexual involutional processes that he may encounter. Effective sexual function for most women also depends upon their knowledge of male sexual physiology in the declining years. Men and women must understand fully the alterations of sexual patterning that may develop if they are to cope effectively with their aging process.