(1) Department of Pan African Studies, California State University Northridge, Northridge, California, U.S.A
(2) Department of Clinical Psychology, California State University Northridge, Northridge, California, U.S.A
* Corresponding Author E-mail: Luciana.Lagana@csun.edu
The study of older women’s sexual health has been very limited. Most of the available research in this area is on Caucasian older women; a few studies have targeted the sexuality of older Black women. There could be several reasons for this and for the common reluctance of these women to disclose information on their sexual health. The aim of this review was to discuss factors influencing older black women’s sexual functioning and their disclosure of sexual concerns.
In this article, we first briefly reviewed the literature on sexual health among older women, then covered historical and social issues that are likely to influence older Black women’s sexuality as well as their common reluctance to disclose intimate details of their lives to their health providers. This information could be important for researchers as well as healthcare professionals. Specific groups of clinicians potentially interested in this discussion are sexual health professionals, couples’ counsellors as well as other professionals attempting to address older patients’ problems such as relationship, intimacy and sex challenges. Without knowledge of critical issues such as the potentially traumatising historical events and the multiple societal pressures that are likely to impact these women’s sexuality and disclosure of sexual concerns, it would be difficult for researchers and clinicians to get an accurate account of older Black women’s sexual needs.
Older Black women’s sexuality is a very delicate and complex topic. We encourage interested professionals to make an effort to become more aware of what is potentially holding back older Black women from disclosing their sexual concerns to them, and have provided some historical information and research suggestions to guide professionals interested in investigating older African American women’s sexuality in a more tactful and culturally-sensitive way.
It is important to investigate the neglected research topic of older women’s sexual health for a variety of reasons. For instance, although it is typically believed that older individuals do not crave sexual interaction, research findings indicate that the desire for sexual intimacy does not necessarily decrease in later life[1,2]. Being older is implicated in the aetiology of sexual disorders. Sexual problems can also be a sign of the presence of one or more diseases such as cancer or an infection[4,5]. Unless these problems are addressed, they could precipitate other disorders including depression. This discussion is particularly salient for older Black women, given that, by 2030, a projected 10% of the United States (U.S.) population over 65 is expected to be African American: but this group will be comprised primarily of women, due to Black men’s higher mortality rates. In this review article, we have discussed possible reasons specific to older Black women’s typical silence regarding their sexual concerns and offered preliminary suggestions on how to potentially minimize the reluctance of these women to discuss sexuality with researchers. This discussion is also pertinent to healthcare providers who are interested in working with this patient population. It should be noted that, to minimize redundancies, we have used the words “Black” and “African American” as well as “sexuality” and “sexual health” interchangeably. Given the paucity of studies on our target population, we have focused on literature that addresses older women and older men as well as older adults of all ethnic backgrounds; however, our discussion of the available literature is geared towards application in the lives of older Black women.
Studies on older adults’ sex and intimate relationships, not specific to older African Americans, have yielded interesting findings that could inform sexuality-focused studies of older Black women populations. Indeed, regardless of race, many factors influence sexuality in older age, including mental and physical health, which both play an integral role. Regarding mental health, in particular, researchers such as Brandenburg et al. noted that depression and anxiety are critical to the development of sexual desire problems as people grow older. Regarding age-related physical changes affecting sexuality, in 2007, Nappi discussed the impact of menopause on older women’s level of sexual desire, noting that, with age, the number of women reporting decreased sexual desire rises. Indeed, age-related decreases in oestrogen levels and other hormones affect sexuality adversely and often have a negative influence on vaginal lubrication. Becoming physically ill in older age can also impact older women’s sexual activity negatively. Moreover, erectile dysfunction, which is common in older men, presents a sex partner problem that could impact older women’s sexual life negatively. According to Jacoby, one-fifth (20%) of all respondents in an AARP study reported having a chronic health problem that restricted their sexual activity; yet, an alarming number said they were not receiving treatment for the impacting health conditions. Additionally, women were less likely to seek treatment for physical problems related to their sexual functioning than men. As reported by Jacoby, although 85% of older women (even those 75 and older) stated that their sexuality was unimpaired by illness, respondents noted that improved health would enhance their sexual pleasure more than any other life change.
Is older women’s sexual functioning indeed typically impaired in older age? Many issues must be clarified before providing an answer to this question. In 2004, Hartmann, Philippsohn, Heiser and Rüffer-Hesse highlighted the need to consider various aspects of older women’s lives before passing clinical judgment on their sexual functioning. This is particularly applicable to hypoactive sexual dysfunction as currently defined by the DSM-5. In their study on variables contributing to low sexual desire in women’s midlife and in the years beyond menopause, factors identified by Hartmann and colleagues as influential on levels of sexual desire included ethnicity, culture, religion, social background, age and expectations regarding sex and performance. In addition, older women’s sexual satisfaction appeared to be more highly dependent on the quality of their relationship with an intimate partner than on physical constraints. Furthermore, for respondents who tended toward sexual dysfunction, if they failed to obtain treatment, their sexual health was likely to worsen, and they eventually accepted this condition as an unavoidable part of their lives. However, on a positive note, for those with a healthy sex life, their enjoyment of sex increased with time.
Perhaps instead of being sexually impaired, older women are seldom sexually active. In support of this statement, an investigation on the sexual functioning of older adults conducted in 2007 by Smith, Mulhall, Deveci, Monaghan and Reid revealed that only 18% of the women in the sample reported being sexually active. Among the sexually inactive women, “no desire” was the reason most often reported for lack of sexual activity. The second one was “no partner.” A limitation of this study (and of several similar ones) is that the sample was predominantly White (83% of the women in particular): this highlights the need for more studies on the sexuality of older women from ethnic minorities. Lending international support to the above findings, Nicolosi et al., in the Global Study of Sexual Attitudes and Behaviours (on 27,500 men and women aged 40 to 80-years-old residing in 29 countries), discovered that the most common sexual problem reported in all 29 countries by women was a lack of interest in sexual activity. This issue must be covered when creating research protocols to assess older women’s sexual health, as the current available literature on reasons for this lack of interest is limited and seldom specific to ethnic minority populations.
There are many non-health-related factors impacting the sexuality of older women. One of them is the lack of available sexual partners, mentioned above, which affects availability of and access to a sexual companion (in the case of heterosexual women). Moreover, life satisfaction and overall well-being are related to older women’s sexual satisfaction, although cultural norms traditionally play a strong role in the sexuality of ethnic minority older women. Another factor that can preclude these women from expressing their sexuality is lack of privacy to engage in sex in a discreet manner. This challenge can surface as a result of a variety of living circumstances, such as residing in an institutional setting that does not give older women the freedom to create sexually intimate bonds, if desired, or living with family members who neither recognize nor respect the sexual needs of older adults. In these settings, finding a way to engage in sexual interactions would be highly problematic at best, if not unfeasible. The difficulties stemming from living in sexually repressing settings can lead to issues such as lack of touching of the older woman, and could precipitate (or be compounded by) other challenges, such as shame over body image (beyond the loss of physical beauty) and prolonged lack of sexual arousal over time (for physiological, psychological and/or social reasons). No wonder some researchers have pointed out that “the speechlessness” surrounding the subject of sex in later life is a contributing factor in lower sexual desire and lower sexual activity level. How could it be otherwise, given the physiological changes affecting sexuality in older age, the lack of available partners, and the multiple kinds of societal pressures exerted on older women of all ethnic backgrounds as a result of a refusal to acknowledge their sexuality or to deem it socially acceptable?
The authors have referenced some of their own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki, 1964, and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies.
At times, researchers interested in studying the sexual health of Black older women encounter difficulty gathering information from this target population, as occurred to the authors in an empirical study published in 2013. In this research endeavour, we recruited 13 Black older women age 57 to 82; one of them described herself as lesbian, one as bisexual and 11 as heterosexual. Via administering a one-on-one semi-structured interview protocol, we identified four major themes related to the sample’s sexuality: having (often unfulfilled) sexual desire; engaging in less sexual activity with advancing age; facing sexuality changes stemming from absence of a spouse and having control over one’s sexual life in older age. Overall, the level of disclosure regarding sexual health from our respondents was minimal. There is certainly a need to find ways to encourage and increase older women’s level of openness about their sexual concerns, especially among ethnic minority populations.
Unfortunately, there are several factors that could impact why older Black women in particular, may tend to disclose little information about their sexual health and concerns to researchers and clinicians. African Americans have a long history of being mistreated by doctors, scientists and researchers. As pointed out by Haynes and Hatch, a major reason for the limited participation of Blacks in health studies is “the Tuskegee” effect stemming from the United States Public Health Service (USPHS) syphilis study at Tuskegee that, most regrettably, involved minority abuse. Motivated by the lessons learned in our aforementioned research published in 2013 and by the scarcity of literature in this area, we have first addressed possible reasons for older Black women’s typical silence when it comes to their sexual concerns. We have focused on possible motivators that yield their reluctance to disclose information of a sexual nature to researchers – which could also apply to healthcare providers interested in better servicing this population. Second, we have provided some suggestions on how to best motivate disclosure of these women’s sexual concerns by referring to the limited pertinent literature on this topic.
Is it best to separate issues of class and sexual orientation when attempting to study older Black women’s sexuality? The answer seems to be no, according to one of the most prominent researchers in this field of study, Rose. Indeed, in her very detailed research in this area, Rose pointed out that this area of research is extremely complex and that class and sexual orientation, if entered into the assessment equation, could complicate matters to the point of confusion. Her reasoning was as follows: she first asked how class status is defined and then, in turn, how it is complicated by race. She noted that a variety of factors are potential markers of class status, including income, quality of life in a given African American community, job status, relative security, education and cultural literacy. For instance, it is possible for some Black women to be raised in families typically defined as working class, but then they acquire jobs perceived by their families as middle class – even though the pay rate is minimal. Conversely, some women who were raised in middle-class neighbourhoods until a certain age find themselves struggling financially later in life. In Rose’s opinion, race complicates class markers significantly. Still, she noted that the aforementioned factors are highly relevant yet hard to research because, in her words, “…understandings of or the definitions of sexual orientation and class status tend to be extremely rigid; you are either working class or not; you are either straight or gay.” In her research in this area, participants’ stories on class and sexual identity were presented in very complex and at times somewhat confusing ways. According to Rose, these complexities would become invisible if the stories told were separated into sexual orientation and class categories. As it pertains to our discussion, perhaps it is best to focus on finding optimal ways in which to respectfully encourage older Black women, “regardless” of their class or sexual orientation status, to express themselves in a research or clinical environment that is conducive to their sexual disclosure.
The silence of African American women about their sexual health and concerns could serve several functions, as indicated by Hines, who noted that only in secrecy could Black women “acquire the psychic space to gather the resources and to hold their own in their often one-sided and mismatched struggle to resist oppression.” The potential benefits of remaining silent may influence African American women’s reluctance to disclose sex issues to researchers, as argued by Collins, who used the example of how White women, during the early twentieth century club movement, “were much more successful in advancing analyses of intraracial gender relations and sexuality than were Black women. In the context of virulent racism, public discourse could leave Black men and women vulnerable to increased sexual violence at the hands of White men,” whereas White women face no such fear. Moreover, Collins argued that “In situations such as these, where regulating Black women’s bodies benefited systems of race, class and gender alike, protecting the safe spaces for Black women’s self-definitions often required public silences about seemingly provocative topics. This secrecy was especially important within a U.S. culture that routinely accused Black women of being sexually immoral, promiscuous jezebels. In a climate where one’s sexuality is on public display, holding fast to privacy and trying to shut the closet door becomes paramount.” This situation created what Hines called a culture of dissemblance, one in which African American women appear outgoing, a public performance that belies and protects a secret world within.
Historically, sexuality in general and sexual desire in particular are further complicated for Black women, as the institution of slavery had a very strong impact on the sex lives of African women as well as their descendants. Taken out of its cultural and natural context, Wyatt contended that “sex became something to be dreaded.” The author highlighted that slaves did not have rights to their own bodies, and that their first sexual encounter was typically a rape experience. Furthermore, according to Wyatt, the institution of slavery “ripped into the hearts and souls of African American women, altering their culture, their families, and most intimately, their sexuality.” While the remnants of slavery have been much debated by notable scholars[25,29], White argued that “the African past lies camouflaged in the collective African American memory . . . a difficult history where not many material goods survived, but rather a preserved memory that still effects how African Americans today believe social relations should be constructed.” In 2004, Hallam pointed out that “the slave owners’ exploitation of Black women’s sexuality was one of the most significant factors differentiating the experience of slavery for men and women. The White man’s claim to the slave body, regardless of the slaves’ gender, was inherent in the concept of the slave trade and was tangibly realized, perhaps no where more than on the auction block, where captive Africans were stripped of their clothing, oiled down, and poked and prodded by potential buyers. The erotic undertones of such scenes were particularly pronounced in the case of Black women.”
Since mid-19th century, the struggles for human rights and empowerment have met with considerable success. However, the hypersexual generalisations that were constructed about African women and their bodies by European explorers and slaveholders are likely to still have significant effects on Black women’s sexual health and, possibly, their sexual disclosure to researchers today. African American women inhabit a gender hierarchy in which inequalities of race and social class have been sexualized. Privileged groups define their alleged sexual practices as the mythical norm and label as deviant and/or threatening those who diverge from this norm[32,33]. For these women, the relationship between gender and race is intensified, producing a Black gendered ideology that may shape ideas about Black femininity. This ideology draws upon widespread cultural beliefs concerning the sexual practices of people of African descent.
Contemporary sexual politics in the U.S. present African American women of all ages with several problems. Moreover, historically, Western social ideology has commonly related Blackness to uncivilized sexuality, as women of African descent have been typically considered as having an animalistic type of sexuality. To provide an example, Sarah Baartmann, better known as Venus Hottentot, is usually recognized as the original icon of Black women’s sexuality. She was an enslaved African woman who was displayed as a sexual “freak” of nature in London and Paris in the early 19th century. Sarah’s body was subjected to all sorts of demeaning and abusive public behaviours, including prodding, pinching and poking in order to please the sexual curiosity of White men and women. Her body was handled as an object; she was not treated as a person, but as an untamed sexual being to control and to use for public amusement. It might be very difficult to delete those horrible images from people’s minds, or simply impossible especially for many individuals who feel affected by this history. Unfortunately, “the treatment of Sarah Baartmann helped to create modern Black sexual stereotypes of the jezebel and the mammy, which, in the U.S., helped to uphold slavery, Jim Crow segregation, and racial “ghettoisation”. After over a century, i.e., in the 1950s, Josephine Baker, an African American singer, dancer, actress and international star, became an icon of Black women’s sexuality. Baker was a civil rights activist, yet she was mainly recognized for her usually topless performances in Europe, and was considered as a woman who enjoyed expressing her sexuality and who regarded being naked a “second skin”.
These potentially traumatising historical and social events could be responsible, at least, in part, for: a) the existence of the speechlessness that surrounds the topic of sex among older Black women, as previously pointed out and b) these women’s challenges with sexual desire and sexual activity, as older Black women might still be influenced by this traumatic past of historical abuse as well as by the current negative social pressures on their sexuality. It would certainly be reasonable for them to experience even more barriers to disclosing their sexual concerns to researchers and healthcare providers than women from other ethnic backgrounds. This topic should be the target of in-depth studies that could provide empirical evidence in support of these discussion points.
What could be done so that researchers and healthcare providers interested in assessing sexual health would succeed at putting these women more at ease, enough to disclose what concerns them about their sexuality? Certainly, it is critical for these professionals to employ cultural sensitivity. Perhaps some women will only disclose detailed sex information to interviewers of their own gender and race, and this preference should be respected and honoured. It is also possible that only the utilisation of mature researchers/interviewers (as opposed to young research assistants – whom we utilized in our aforementioned study in this area) would allow older Black women to feel safe when talking about their sexuality. Storytelling in particular could be a useful method for tactfully enquiring into the factors affecting the well-being of women of African descent. Researchers must keep in mind that knowledge gained through personal experience and communication via storytelling is especially rooted in the culture of African American women.
According to DeBose, older Black women can benefit from stories that will help them understand and process their healthcare experiences. Informal sharing of stories has typically been an effective way to discuss health without the stigma of sharing forbidden secrets. The participants in DeBose’s study on ten African American women (aged between 50 and 89) were recruited through word of mouth and a flyer within the membership of the African American Health Network (AAHN) of Dane County, Wisconsin, and the African American Council of Churches, Inc. (AACC). The investigator made a particular effort to ensure that the women had an understanding of the informed consent process by asking them to tell her about what giving consent for the study meant to them. This technique allowed DeBose to address ethical considerations of the study, which emphasized that the participants had the right to refuse to answer any question, as well as the right to not be audiotaped. Interested researchers could consider adopting these strategies, as having the right to refuse to answer uncomfortable questions and to not allow recording could make older Black research participants more inclined to share content of a very intimate nature.
It should be kept in mind that simply telling one’s story is not simple, especially when it concerns sex. Black women’s sexual lives, like those of many women, sometimes entail abuse and mistreatment perpetrated by men. According to Rose, for African American women to discuss these issues would involve making public statements concerning Black men that would lend support to stereotypical images of African American men as dysfunctional, violent and criminal. It is difficult to be pinned between the distorted myths about sexuality in the African American community that support demeaning stories about men and women from this group and the sex myths that are utilized to keep women in a subordinate position, in general: this is where many Black women find themselves, as Rose stated. She also pointed out other challenges faced by African American women, in particular, when it comes to sex and intimate relations, citing the following examples as pressing concerns: “How is our sense of sexual belonging affected by the fact that desirable women over forty on TV are all skinny and almost always white?”; “Will my family disown me if I date outside my race?” and “Why can’t I find a Black man to date?” and adding “The stories behind these questions are rarely heard in our everyday lives, even though our society is fixated on issues of race and sexuality. In our popular culture, we are bombarded by stories about sex and romance, but we almost never hear what Black women have to say. The sexual stories that Black women long to tell are being told in beauty parlours, kitchens, health clubs, restaurants, malls and laundry rooms, but a larger, more accessible conversation for all women to share and from which to learn has not yet begun.” It makes sense, then, that Black women of all ages tend to resort to discussing their sexual concerns primarily within their trusted circle of women friends while being silent with researchers and clinicians.
In Rose’s opinion, there are two approaches to “breaking the silence” in storytelling research, neither of which can properly counter the historical forces that shape Black women’s sexuality. In one approach, the author/researcher/interviewer can frame the stories around a central thesis. While this approach may “provide insight into similarities and differences, it breaks up the stories into fragments that are animated through the analysis the author provides rather than appreciating them for their own logic and form (thus we do not) hear the women’s voices in all their glorious, sometimes contradictory, complexity.” The second approach involves placing sexual stories into what Rose called “story containers”– such as “rape victim,” “incest survivor” or “lesbian.” Rose stated that, although this style of framing stories has been “helpful in bringing denied experiences, quietly held sexist stigmas, and crimes into public view by isolating and illuminating them, they [also] give us a neat and sometimes one-dimensional understanding of how sex and sexuality are experienced.” More research is needed to identify the best and most tactful ways in which to encourage older Black women to disclose their sexual concerns.
Regardless of the specific research approaches, as long as these methods are respectful and culturally relevant to the population studied, it is possible for researchers to make the process of investigating older women’s sexuality more comfortable for these women. Older women themselves do believe that this could happen, as Jones, in 2011, reported that older research participants felt that researchers could indeed become experts at challenging the negative impact of contextual issues on the research process and could also help build trust in this process. Moreover, according to Frith, when assessing older research populations, it is particularly important to create an atmosphere of trust by promising that the two ethical requirements of confidentiality and anonymity would be met. The combined implementation of all the aforementioned research strategies could foster the creation of a comfortable and enabling environment where two strangers could engage in a focused conversation covering sexuality issues.
One final point of discussion to emphasize is the poorly-met need to encourage older Black men and women to disclose sexuality issues (within a research or healthcare environment) related to potential contraction of diseases typically transmitted via sexual activity. The possibility of contracting a disease via sex could be one of the motivators that is precluding our target population from engaging in sexual interactions, and reasonably so, given that the statistics on this topic are not in favour of African Americans. Indeed, older individuals, in general, and African American older adults, in particular, are especially at risk for Human Immunodeficiency Virus (HIV)/Sexually Transmitted Diseases (STDs) because neither they nor their doctors usually think of them as being at risk. As reported by Binson, Pollacek and Catania, in a national survey by the National AIDS Behaviour Surveys that paid particular attention to “high-risk cities,” out of over 3,000 respondents, African American women over the age of 40 had the highest level of prevalence of HIV risk behaviours (12.4%). The authors pointed out that, among women with 12 years of education, African American women were much more likely to engage in risk behaviours, as opposed to Hispanic women (6.4%) and White women (6.6%). Separated or divorced respondents were also more likely to report risk behaviours than widowed or married respondents. Alarmingly, Binson and colleagues noted that almost 90% of the women who reported engaging in a risk behaviour did not perceive themselves to be at risk. As such, many cases of high risk behaviour may not be reported to healthcare providers; thus, we see a continual spread of these highly contagious diseases.
Even if the U.S. prides itself on having the most advanced medical care in the world, many older individuals do not have access to it, and therefore suffer from undiagnosed illnesses, including depression as well as HIV/STDs. Lower income individuals have considerably less access to healthcare than wealthier individuals, and disparity in healthcare insurance coverage is only part of the problem. Other reasons include age, education, cultural background and the bias of healthcare providers, as noted by researchers such as Hayward, Shapiro, Freeman and Corey. This information highlights the need to conduct high-quality sexuality research that includes contraceptive sexual health behaviours and practices in an effort to more comprehensively research and clinically serve our target population.
There are many possible reasons for the common reluctance of older Black women to disclose information about their sexual health to researchers and clinicians. The aforementioned shameful historical events and societal reactions perpetrated against African Americans have contributed to creating a hostile environment in which our target population would reasonably experience reluctance to disclose intimate sex issues. No matter how far away in the past some of these events are, their repercussions can still live in current times. In support of this statement, Wyatt asserted that “the roots of human sexuality lie in the survival needs of the past.” She contended that slavery “ripped into the hearts and souls of African women, altering their culture, their families, and most intimately their sexuality. It would [thus] be naïve to think that time has healed those wounds or to believe that they are no longer relevant to the sexual experience of African American women today.”
Given these circumstances, it is particularly important to find ways in which to research older Black women’s sexuality in a highly respectful and culturally appropriate way. In the case of Rose’s high-quality sexuality research on Black women, the sexual stories told to her by the research participants were allowed to unfold in the context of these women’s lives, revealing that “Black women share important contemporary social, political, and cultural histories with one another and share other histories with women from diverse backgrounds. Sexuality is considered a private matter; yet it has a powerful and volatile public social life.” Researchers interested in this understudied sex research area need to properly take into account the historical and societal issues that are likely to impact older Black women’s sexuality and sexual disclosure within a research or clinical setting.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.