The Impact of Aging on Sexual Function in Women and Their Partners

Transcription

1 Archives of Sexual Behavior, Vol. 31, No. 5, October 2002, pp ( C 2002) The Impact of Aging on Sexual Function in Women and Their Partners Sheryl A. Kingsberg, Ph.D. 1 Received December 5, 2000; revision received April 24, 2002; accepted April 24, 2002 Aging has a powerful impact on the quality of relationship and sexual functioning. The psychological impact of aging after midlife is a particularly timely topic, given improved medical and psychological understanding of sexuality in both women and men as well as significant improvement in the conceptualization of female sexuality and evolving treatment advances for female sexual dysfunctions. It is time to dispel the stereotype of the midlife woman in order to more effectively address emotional and sexual issues arising in her relationships. Regardless of the length or nature of the relationship, its quality is enhanced by emotional intimacy, autonomy without too much distance, an ability to manage stress, and to maintain a positive perception of self and the relationship. To understand and treat effects of aging on sexuality, it is important to address the three components of sexual desire: drive, beliefs/values, and motivation, as well as the social context of a woman s life. It is also essential to understand how the physiological changes in female as well as male sexual functioning impact desire. Further, other health-related changes that occur with aging must be recognized and addressed. KEY WORDS: aging; female sexuality; hormone replacement therapy; postmenopausal sexuality. INTRODUCTION The psychological and physiological impact of aging on sexuality in women is a particularly timely topic for a number of reasons. The first reason I have labeled the Viagratization of America. Whether or not Viagra (and now the other PDE5 inhibitors) ultimately lives up to its promise to be the sexual salvation for aging men and their increasingly unreliable penises (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994), its arrival into our culture has renewed attention to the topic of sexuality in older people. Since Viagra came to market in March 1998, sex in aging Americans has been the cover story of virtually every magazine and newspaper. Second, and almost as obvious a reason, is the fact that the baby boomers have arrived at middle age, a trend popularly termed the graying of America. In the next two decades, almost 40 million women will experience menopause. Women can now expect to live an average of 82 years, which means that women will now live one third 1 Departments of Reproductive Biology and Psychiatry, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Euclid Avenue, Cleveland, Ohio 44106; sheryl.kingsberg@uhhs.com. of their lives postmenopausally. Third, the baby boomer generation has never been known for passively accepting models for living handed down from prior generations. It is already evident that the women of this generation are negotiating midlife and menopause in different ways from their mothers and grandmothers. Cultural stereotypes of the middle-aged woman as gray-haired, frail, and asexual have given way to images of strong, active, and sexual women. Examples include Sigourney Weaver, age 51, who after 20 years in her role as Lt. Ripley from the Alien movie series is stronger and more independent than ever, and Tina Turner, who, at 62, arguably has the sexiest legs and the most energy of the entire entertainment industry. Fourth, and most central to the topic, interest and research on postmenopausal sexuality has finally begun receiving the kind of attention that has resulted in a more refined conceptualization of women s sexual lives and improvements in treating sexual problems. AGE OF RELATIONSHIP VERSUS AGE OF PARTNERS Sexual activity for women often occurs within the context of a relationship. However, the age and /02/ /0 C 2002 Plenum Publishing Corporation

2 432 Kingsberg developmental stage of life of a woman provide no reliable predictors of where she may be in a relationship. Menopausal women and partners may be involved in a new passionate relationship, a long-standing intimate relationship, a long-standing nonintimate/distant relationship or no relationship at all. Therefore, physicians must be careful not to make assumptions about the type of relationship in which their menopausal patients are involved. Women may benefit from a reminder to hold realistic expectations about sexuality in long-standing relationships (that are not related to aging) as well as to hold realistic expectations that are about age limitations. Schnarch (1997) reminds us to appreciate the advantages of longer relationships and more mature partners. He argues that most of us are best able to achieve our sexual potential in midlife. His distinction between genital prime and sexual prime suggests that sexual peak has more to do with one who is as a person than with the speed at which one s body works. True sexual intimacy is only achievable by individuals who are mature, independent, and have good self-esteem and who trust and respect their partners; in short, those who have the capacity for emotional intimacy. Maturity and independence are more likely to be attained by men and women who are also chronologically mature. Similarly, lasting or long-term relationships are fairly exclusive to older couples because these terms require by definition that a relationship exists for many years. Recall, however, that older age does not effectively predict that someone is in a long-term relationship just as older age is not a guarantee that someone actually has achieved independence and emotional maturity. Older age can be considered a necessary but not sufficient component to maturity. Although a long-term relationship allows for true sexual intimacy, there are also some compelling sexual advantages that are only experienced within the context of a new relationship. The excitement of new love (or even lust), the mystery, the challenge, and the discovery are often the ingredients that make sex during this stage of a relationship incredibly passionate and exciting. There is much less risk of emotional dependence early on because, typically at this early stage of a relationship, each partner s identity is still independent of the other (though possibly not fully developed or healthy). But don t confuse new with young. These new exciting relationships are as likely to occur in midlife as in young adulthood. THE IMPACT OF AGING ON SEXUALITY The impact of aging on sexuality can be understood only by putting it in a greater context of all adult sexuality. The fact is that sexual dysfunction is highly prevalent in both men and women. The National Health and Social Life Survey (NHSLS; Laumann, Paik, & Rosen, 1999) surveyed 1,410 men and 1,749 women between the ages of 18 and 59 years and reported that 31% of men and 43% of women had experienced a sexual dysfunction. However, the NHSLS also noted that the prevalence of sexual dysfunction in women, unlike that in men, tends to decline with age. This corresponds with the results of the Massachusetts Male Aging Study (Feldman et al., 1994), which reported that by age 40, 40% of the men surveyed experienced mild-to-severe erectile dysfunction and this increased to 67% by age 70. In contrast, the 1998 NCOA (The National Council on the Aging) survey of 1,300 older (over age 60) Americans helped to provide a slightly different perspective on sexuality in this population (NCOA, 1998). Their results indicate that sexual activity plays an important role in relationships among these older men and women. Forty-eight percent reported that they were sexually active (sex at least once per month). Of these respondents, 79% of men and 66% of women said that sex was an important component of their relationship with their partner. Seventy-four percent of the sexually active men and 70% of the sexually active women reported being as satisfied or even more satisfied with their sexual lives than they were in their 40s. It is fair to state that when older people are sexually abstinent, it is likely because they have no available partner or because of health problems. AGE-RELATED FACTORS THAT IMPACT SEXUAL FUNCTIONING Female sexual satisfaction does not appear to decline appreciably with age (Avis, Stellato, Crawford, Johannes, & Longscope, 2000; Laumann et al., 1999). However, the physical changes that may occur as a result of the menopausal transition have the potential to interfere with sexual functioning. Declining estrogen levels that occur during perimenopause often result in vaginal dryness and atrophy due to diminished blood flow to the vagina. The vagina is a cylindrical organ 7 15 cm in length. With sexual arousal, lubrication occurs as a result of secretions from the uterine glands and transudate from the subepithelial vasculature. The blood and nerve supplies to the vagina are similar to those of the penile shaft. Arterial blood flow branches off the uterine, pudendal, and ovarian arteries. The changes in the epithelial lining of the vagina occur relatively rapidly as estrogen levels decline. Subsequent vascular, muscular, and connective tissue changes occur over time. Decreased vascularization starves the

3 Aging and Female Sexual Function 433 surrounding tissues of nutrients and makes it more difficult for engorgement and lubrication. The vagina also loses its elasticity. Estrogen replacement therapy, unless medically contraindicated, will often prevent genital atrophy and preserves the epithelial integrity of urogenital tissues (Freedman, 2000). Topical estrogen cream or a vaginal estradiol ring may also help prevent genital atrophy and vaginal dryness (Berman & Goldstein, 2001). The clitoris is composed of the clitoral gland and two corporal bodies that extend for perhaps 9 10 cm behind the head of the clitoris and along the undersurface of the vagina. These corporal bodies are made of erectile tissue covered with a unilaminar tunica, rather than the trilayer tunica found in the penis. Therefore, the clitoris can become engorged, but it does not become erect. Clitoral changes from aging include shrinkage, a decrease in perfusion, diminished engorgement during the desire and arousal phases, and a decline in the neurophysiological response, including slowed nerve impulses and a decrease in touch perception, vibratory sensation, and reaction time. Decreased muscle tension may increase the time it takes for arousal to lead to orgasm, diminish the peak of orgasm, and cause a more rapid resolution. Additionally, the uterus typically contracts with orgasm, and with advancing age, those contractions may become painful. However, although all this sounds pretty ominous for older women, the actual perception of sexual satisfaction does not necessarily change. ANDROGENS AND POSTMENOPAUSAL SEXUALITY The role of androgens and androgen replacement for postmenopausal women is currently receiving tremendous attention and has incurred lively debate. The fact that androgens have a role in female sexual drive has been known for 60 years (Greenblatt, 1942). However, the current controversy revolves around whether there is a clinical syndrome of androgen deficiency. Women achieve peak androgen production in their mid-20s. Beginning in their early 30s, they gradually lose circulating testosterone and the adrenal preandrogens (androstenedione [A] and dehydroepiandrosterone in an agerelated fashion; Davis, 2001). By the time most women reach their 60s, their testosterone levels are half of what they were before age 40. In contrast to the gradual decline in testosterone of naturally menopausal women, there is a sudden decline in testosterone following bilateral oophorectomy because the ovaries produce 40% of circulating testosterone. Testosterone, together with its metabolite dihydrotestosterone is the most potent endogenous androgen in both men and women. Testosterone is bound to albumin and sex hormone-binding globulin (SHBG). During the time of the perimenopausal transition, as estrogen levels are declining, women also experience a decrease in SHBG, which binds both estrogen and testosterone and, in fact, tends to bind testosterone more than it does estrogen. Some perimenopausal women will notice an increase in sexual desire and activity, perhaps because the declining levels of SHBG frees up more testosterone. In contrast, some premenopausal women who use oral contraceptives may increase their SHBG levels and lower their free testosterone levels and may notice a decrease in sexual desire. In response to the controversy over whether androgen deficiency exists in women, in June 2001, a panel of experts reviewed the existing literature in this area. This panel proposed that there is a clinical syndrome that they have labeled Female Androgen Insufficiency (FAI). FAI is defined as a pattern of clinical symptoms in the presence of decreased bioavailable testosterone and normal estrogen status. The clinical symptoms include impaired sexual function, mood alterations, and diminished energy and well-being (Bachman et al., 2002). The panel used the term insufficiency and not deficiency because we do not yet know enough about normal levels of androgens in women to be able to state what is considered a deficiency. There is not yet a clear range below which a deficiency can be diagnosed. There are no consistent laboratory assessments. Most commercially available methods are inaccurate or unreliable. Equilibrium dialysis is the current gold standard but it is not readily available in most laboratory settings. In addition to difficulty with determining normal values, there is considerable variability among women who show low levels of free testosterone. Not all women experience the symptoms, even when they may have declining levels of free testosterone. There are also some long-term side effects, some potentially irreversible. These include virilization (e.g., hirsutism, clitoral enlargement, deepened voice), acne, hypercholesterolemia, and liver damage (Berman & Goldstein, 2001). Another problem with the concept of female androgen insufficiency is that healthcare providers may overuse this simple medical diagnosis. Unfortunately (or fortunately), this is not the case with regard to any female sexual dysfunction, and this is particularly true with regard to aging women and decreased sexual desire. Female sexuality and hypoactive desire disorder are very complicated and cannot be summed up by a simple biologic theory. In fact, even when androgen insufficiency may be involved, there are a number of other psychosocial factors that are at

4 434 Kingsberg least as important, if not more important, in understanding the problem and treating it. AGING AND SEXUAL DESIRE Hypoactive sexual desire disorder is the most prevalent female sexual dysfunction for all women (Laumann et al., 1999). It is also the sexual dysfunction that has often been linked to menopause because of the declining levels of testosterone that occur during this time. However, recent large-scale studies do not support this long-held belief. Instead it is age much more than menopausal status that is related to decreased sexual drive. In fact, one of the most significant and universal changes that occur with age is a decline in the drive component of sexual desire. The false assumption that menopause automatically results in loss of sexual drive has often resulted in haphazard and inappropriate treatments. Unfortunately, many healthcare providers and women themselves do not accurately understand the complexity of desire. Desire refers to one s interest in being sexual and is determined by the interaction of three related but separate components: (1) drive; (2) beliefs/values; and (3) motivation (Levine, 1992). Drive is the biologic component of desire. It is the result of neuroendocrine mechanisms and is experienced as spontaneous, endogenous sexual interest. Drive is typically manifested by sexual thoughts, feelings, fantasies or dreams, increased erotic attraction to others in proximity, seeking out sexual activity (alone or with a partner), and genital tingling or increased genital sensitivity. This is the component that is impacted by declining testosterone levels. The second component of desire reflects an individual s expectations, beliefs, and values about sexual activity. The more positive the person s beliefs and values are about sexuality, the greater the person s desire to behave sexually. The third component of desire is the psychological and interpersonal motivation. Motivation is driven by emotional or interpersonal factors and is characterized by the willingness of a person to behave sexually with a given partner. This component tends to have the greatest impact overall on desire and is the most complex and elusive. This distinction between drive and desire is absolutely essential for any physician assessing or treating sexual problems because treatment is vastly different on the basis of which component or components of desire have declined. For example, a woman might have a very strong sexual drive but if she is not motivated to be sexual, say if she is angry with her partner, dealing with a stressful work problem or suffering from depression, she will not act on the drive. In fact, it is virtually wiped out. On the other hand, if a woman has lost some of her drive but remains motivated to be close to and intimate with her partner, then despite having little physical cues or interest, she still enjoys the sexual experience. This differentiation of drive from desire is particularly important to the understanding of female sexuality and points out some of the gender differences in prevalence of particular sexual problems. It also underscores the relative gender differences in the sexual response cycle itself and is very consistent with Basson s model of a nonlinear female response cycle (Basson, 2000). For many women, particularly postmenopausal women, drive fades and is no longer the initial step (or never was) in the response cycle. Instead, desire follows arousal and many women begin to respond from a point of sexual neutrality. Arousal may come from a conscious decision or from a stimulus or as a result of seduction or suggestion from a partner (receptivity). Healthcare providers must understand this to normalize this reality for women who have come to believe that because the initial drive has gone they have a sexual dysfunction (which then can lead to a self-fulfilling prophecy). PSYCHOSOCIAL FACTORS IMPACTING SEXUALITY In addition to understanding desire and the female response cycle in order to fully understand the complexity of female sexuality, it is helpful to observe it from a completely different context than medicine has done so far social psychology theory. The first social psychology concept that is relevant to female sexuality and desire is called Self-perception theory. Self-perception theory proposes that people make attributions about their own attitudes, feelings, and behaviors by relying on their observations of external behaviors and the circumstances in which those behaviors occur (Bem, 1965). Consider, for example, a 55-year-old woman who has been married for 20 years. Throughout her marriage, she has had drive to be sexual about once per week but her husband has had the drive to be sexual three times per week. This has resulted in the husband always being the initiator. On the basis of this, the wife observes her own behavior and sees that she only engages in sex when asked. Even though she was often receptive to the initiation and enjoyed the encounters, her self-perception is that she has little desire and is not a sexual person because she hardly ever thinks of it on her own and never initiates. Another example is the self-perceptions that occur as a result of the disadvantage of long-term relationships. In this case, both partners observe that they are no longer passionate with each other. When they were first lovers,

5 Aging and Female Sexual Function 435 it was exciting and the challenge, mystery, danger, and novelty kept the passion alive. But as with every longterm relationship, passion ebbs as comfort, security, and partnership step in. But many couples do not understand this natural occurrence and perceive it as a flaw in their own relationship. Therefore, they observe their own decline in passion and interpret this as meaning they no longer desire their partner. The second social psychology concept is called the overjustification hypothesis. This predicts that when an external reward is given to a person for performing an intrinsically rewarding activity, the person s intrinsic interest will decrease (Lepper, Greene, & Nisbett, 1973). In this case, if this 55-year-old woman responds to her husband s sexual initiation and the result is that she experiences a reward, such as relief from guilt (a form of negative reinforcement), relief from a whiney crabby husband, or lots of gratitude and more chores done the next day, the actual enjoyment of the sexual encounter may decline for her. Why? Because she now interprets her enjoyment as being primarily from the reward instead of the actual activity. We can also explain this in the opposite direction using the concept of insufficient justification. This concept is based on the classic cognitive dissonance theory, which states that an inconsistency between two cognitions or between a cognition and a behavior will create such discomfort in a person that they will alter one of the cognitions or behaviors to restore consistency and reduce this distress (Festinger, 1957). If this same woman responds to her husband s advances but does not perceive any external reward for this, that is, no relief of guilt, no reduction in whining, no gratitude and so forth, the need for cognitive balance or consistency between her observed behaviors and thoughts would lead her to attribute her behavior to intrinsic enjoyment of sex. One of the classic cognitive dissonance studies illustrates this wonderfully (Festinger & Carlsmith, 1959). In this study, participants participated in a dull experiment and were then paid either $1 or $20 to tell potential participants that the experiment had actually been interesting and fun. When the original participants were subsequently asked to evaluate the dull experiment, the group that was paid $1 had changed their attitude toward the experiment and described it as actually being enjoyable. The investigators concluded that the $20 group had sufficient justification for lying and thus did not feel any dissonance and had no need to alter their cognitions and continued to consider the task as dull. The dollar group felt insufficient justification for lying and therefore felt dissonance, which they reduced by changing their attitude and deciding that the experiment was actually fun. The importance of recognizing how women interpret their own behaviors cannot be overstated. Many women, because of self-perception theory and overjustification, perceive sex as a chore or an obligation rather than an enjoyable experience and consider themselves sexually inadequate. In addition, many couples in long-term relationships misinterpret the natural decrease in excitement and passion as being a symptom of a failed marriage. Therefore, even if healthcare providers improve drive and overall desire but do not address and then alter these long-held misattributions with patients, treatment will be undermined. Healthcare providers must also be sensitive to a patient s culture to gain an accurate assessment of her sexual functioning. A woman s sexual self-perception is influenced by her race, gender, ethnicity, educational background, socioeconomic status, sexual orientation, financial resources, and religion. For example, in many Asian societies, women are expected to be obedient, yielding, timid, respectful, and unselfish (American Medical Association, 2001). Obviously, this culturally determined behavior pattern could greatly impact the sexual lives of women who follow it. Culture also influences women s perceptions of menopause and its impact on health, selfimage, and sexuality. Pharmacia Corporation recently surveyed 1,200 women to see how ethnicity impacted these perceptions of menopause. They found that African American women were the most optimistic, Caucasian women were the most anxious, Asian women were more muted about symptoms, and Hispanic women were the most stoic (Pharmacia Corporation, 2001). AGE-RELATED FACTORS: THE IMPACT OF PARTNER SEXUAL DYSFUNCTION In keeping with this model of looking at context to understand female sexuality, one of the most significant psychosocial or contextual variables that affect women is the impact of their partner having a sexual dysfunction. Many older heterosexual couples cease being sexual because the male partner s interest declines, usually because of his experiencing erectile dysfunction. Erectile dysfunction is a major source of poor body image and resulting low desire for men. Many postmenopausal women are abstinent because of their male partner s erectile difficulties or his decline in drive. The Massachusetts Male Aging Study (Feldman et al., 1994) indicates that by middle age, the majority of men will experience some erectile dysfunction. Men who had mild dysfunction in their 40s tended to progress to moderate or complete dysfunction as they age. In midlife, men begin to experience changes in hormone levels, blood flow, libido, sensitivity, and ejaculation. Those changes

6 436 Kingsberg may compromise their ability to achieve and maintain erections as well as the quality of the erections. Arousal takes longer to achieve and the plateau phase is prolonged, delaying ejaculation. In addition, ejaculation may be slow or absent. Overall, with age, blood flow to all organs decreases (Feldman et al., 1994; Schiavi, 1999). Although Viagra has helped many men overcome erectile dysfunction, a problem to recognize is that it may now cause a shift in a couple s sexual equilibrium. As women first adjusted to the sexual equilibrium of abstinence due to their partner s dysfunction, now they must once again accommodate to another change in equilibrium. This creates a challenge. Not only do older people require a longer adjustment period to make the necessary accompanying cognitive shift, but older women definitely need time for their bodies to readjust to a partnered sexual life. However, give a man a reliable erection, and he typically wants to immediately use it (that is, unless there are other psychogenic factors contributing to avoidance and low desire other than an unreliable penis). Unfortunately, if he and his female partner have not had intercourse for a long time, her aging vagina has likely narrowed and atrophied and will not immediately accommodate a penis without risking pain and/or injury. This may lead to a secondary female sexual dysfunction of dyspareunia or vaginismus. For heterosexual postmenopausal women who have been sexually abstinent for a long time, they must begin by slowly stretching and exercising their vaginas. They need to start by penetration with a finger or dilator and gradually stretch the vagina to accommodate a penis. They cannot return to sexual functioning instantaneously, if sexual functioning for them has always meant intercourse. AGE-RELATED FACTORS: HEALTH CHANGES Not only does the aging body experience problems with sexual functioning, but also the likelihood of developing other health problems increases in older age with a subsequent impact on relationships and sexuality. Sexual problems may be primarily due to physical limitations, lack of energy, side effects of medications, or poor self-image as a sick person. From minor problems such as decreased energy or strength to major problems such as cardiovascular disease, arthritis, cancer, diabetes, and other serious illnesses, the physical decline of the aging body must be faced and accommodated to maintain a satisfying sexual life. The equilibrium of the emotional component of a relationship also changes when one or both partners in a couple become ill or develop chronic health problems. One partner may end up as the nurse or fulltime caregiver to the other. Even excluding the physical problems, the imbalance of these roles in this case would likely result in sexual problems with one or both partners losing desire. TRANSLATING THEORY INTO PRACTICE: WHAT IS THE RELEVANCE TO HEALTHCARE PROFESSIONALS TREATING PERI- AND POSTMENOPAUSAL WOMEN? Although aging may contribute to changes in the sexual dynamics of a relationship, a number of treatment modalities are available, both psychological and medical. An extensive review of these treatments, which include counseling and medical interventions, is beyond the scope of this paper. In fact, such detail works against the main point; healthcare providers do not need to be trained as sex therapists to effectively address many of the sexual problems of their peri- and postmenopausal patients. Instead, physicians can provide help simply by minimally expanding what they are already trained to do: first, assess and evaluate. Second, treat and/or refer. Simply initiating a discussion of sexual concerns is often the most valuable component to treatment for women and their partners. By asking about sexuality, the healthcare provider informs the patient that it is appropriate to discuss sexual problems in that setting and validates an older woman s self-perception as a sexual being. It is hard to provide an effective intervention, regardless of the type of treatment, if there is no mention of a problem. Healthcare providers can be extremely helpful in giving permission to women to expand or change their sexual repertoire or by providing basic sex education. For example, many couples are ignorant of the fact that despite erectile dysfunction, men are still able to experience desire, arousal, and orgasm. Despite our sexually enlightened culture, many older couples still hold onto fairly restrictive and conservative views of what is appropriate and normal. Therefore, treatment would be defined as helping older women and couples to redefine what normal sexual activity entails. For example, the suggestion that some heterosexual couples may no longer want to rely on intercourse as their main sexual event can provide an optimistic perspective for couples having difficulty due to genital atrophy or erectile dysfunction. It may be difficult, though very satisfying, for older couples to move away from the standard missionary position and intercourse and toward different positions and ways of stimulation (e.g., increased use of oral sex, manual stimulation, sexual aids, and sensual nongenital activities like bathing together, massage, or erotic movies/literature; Leiblum, 1991). Change does not have to be extreme for couples to notice significant improvement in sexual fulfillment. It may imply something

7 Aging and Female Sexual Function 437 as simple (but often not considered) as suggesting that couples make love in the morning when older people have more energy rather than late in the evening when there is a greater likelihood of fatigue. Furthermore, it is important to remind older couples to learn to communicate better both in and out of bedroom. As their sexual repertoire requires some adjustment or change, a couple needs to effectively communicate in order to smoothly accomplish this. In addition, communication itself can be seductive, enticing, and sexual. Effective communication in everyday life is also important for the quality of the overall relationship, which is also critical to couples sexual lives. Finally, healthcare providers must be culturally competent. Cultural competence is defined as the knowledge and interpersonal skills that allow providers to understand, appreciate and work with individuals from cultures other than their own (American Medical Association, 2001). Healthcare providers must know when and how to present questions and information so that they respect cultural values. REFERENCES American Medical Association. (2001). Talking to patients about sex: Training program for Physicians. Retrieved from Avis, N. E., Stellato, R., Crawford, S., Johannes, C., & Longscope, C. (2000). Is there an association between menopause status and sexual functioning? Menopause, 7, Bachman, G., Bancroft, J., Braunstein, G., Burger, H., Davis, S., Dennerstein, L., et al. (2002). Female androgen insufficiency: The Princeton consensus statement on definition, classification, and assessment. Fertility and Sterility, 77, Basson, R. (2000). The female sexual response. A different model. Journal of Sex and Marital Therapy, 26, Bem, D. (1965). An experimental analysis of self-persuasion. Journal of Experimental Social Psychology, 1, Berman, J. R., & Goldstein, I. (2001). Female sexual dysfunction. Urologic Clinics of North America, 28, Davis, S. R. (2001). Testosterone treatment: Psychological and physical effects in postmenopausal women. Menopausal Medicine, 9(2), 1 6. Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Krane, R. J., & McKinlay, J. B. (1994). Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. Journal of Urology, 151, Festinger, L. (1957). A theory of cognitive disonnance. Stanford, CA: Stanford University Press. Festinger, L., & Carlsmith, J. (1959). Cognitive consequences of forced compliance. Journal of Abnormal and Social Psychology, 58, Freedman, M. (2000). Sexuality in post-menopausal women. Menopausal Medicine, 8, 1 4. Greenblatt, R. B. (1942). Hormone factors in libido. Journal of Clinical Endocrinology and Metabolism, 3, 305. Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States. Journal of the American Medical Association, 281, Leiblum, S. R. (1991, October). The midlife and beyond. Paper presented at the 24th Annual Postgraduate Course of the Psychology Professional Interest Group of the American Fertility Society on Sexual Dysfunction: Patient Concerns and Practical Strategies, Orlando, FL. Lepper, M., Greene, D., & Nisbett, R. (1973). Undermining children s interests with extrinsic rewards: A test of the overjustification hypothesis. Journal of Personality and Social Psychology, 28, Levine, S. B. (1992). Sexual life. New York: Plenum. Pharmacia Corporation. (2001, November 15). New research on menopause and sexuality finds women are not seeking medial help for chronic symptoms affecting intimate relationship (Press release). Peapack, NJ. Author. Retrieved from com/newsdisplay.asp Schiavi, R. C. (1999). Aging and male sexuality. Cambridge, UK: Cambridge University Press. Schnarch, D. (1997). Passionate marriage. New York: Henry Holt. The National Council on Aging (1998, September). Healthy sexuality and vital aging. Retrieved from natural part.htm