ABSTRACT

Objectives.

This systematic review aimed at assessing the associations between sexual health and subjective well-being in older age groups (i.e. people aged between 40 and ≥90 years).

Methods.

A systematic search was conducted of the Web of Science, MEDLINE, EBSCO, Scopus, SciELO and LILACS (Latin American and Caribbean Health Sciences Literature) databases for studies published until September 2021. Search strings included a combination of terms such as “sexual health” or “sexuality” and “well-being” and terms related to the measures that assess the constructs of interest. This systematic review followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results were grouped into four categories that assess the interplay between sexual health and subjective well-being: cognitive and attitudinal factors, sexual behavior, sexual function and sexual satisfaction. The subjective well-being domains that were analyzed were life satisfaction, positive and negative affect, and psychological well-being.

Results.

A total of 15 quantitative studies were reviewed, of which 14 were articles and 1 was a doctoral dissertation. Findings suggest that living a fulfilling sexual life is an essential part of subjective well-being.

Conclusions.

This review suggests that programs aiming to promote well-being in older age groups should also encourage a fulfilling sexual life.

Keywords
Aging; sexuality; sexual health; personal satisfaction

RESUMEN

Objetivos.

El objetivo de esta revisión sistemática es evaluar las asociaciones entre salud sexual y bienestar subjetivo en grupos de mayor edad (es decir, personas entre 40 y 90 años o más).

Métodos.

Se realizó una búsqueda sistemática en las bases de datos Web of Science, MEDLINE, EBSCO, Scopus, SciELO y LILACS (Literatura Latinoamericana y del Caribe en Ciencias de la Salud) de estudios publicados hasta septiembre del 2021. Las cadenas de búsqueda incluyeron una combinación de términos como “salud sexual” o “sexualidad” y “bienestar” y términos relacionados con las medidas que evalúan los constructos de interés. Esta revisión sistemática siguió las directrices PRISMA (sigla en inglés de elementos de referencia para publicar revisiones sistemáticas y metaanálisis). Los resultados se agruparon en cuatro categorías que evalúan la interacción entre la salud sexual y el bienestar subjetivo: factores cognitivos y actitudinales, comportamiento sexual, función sexual y satisfacción sexual. Los dominios de bienestar subjetivo analizados fueron la satisfacción vital, el afecto positivo y negativo y el bienestar psicológico.

Resultados.

Se revisaron 15 estudios cuantitativos en total: 14 artículos y 1 tesis doctoral. Los resultados indican que experimentar una vida sexual satisfactoria es una parte esencial del bienestar subjetivo.

Conclusiones.

Esta revisión sugiere que los programas destinados a promover el bienestar en los grupos de mayor edad también deben fomentar una vida sexual satisfactoria.

Palabras clave
Envejecimiento; sexualidad; salud sexual; satisfacción personal

RESUMO

Objetivos.

Esta revisão sistemática teve como objetivo avaliar as associações entre saúde sexual e bem-estar subjetivo em faixas etárias mais velhas (ou seja, pessoas com idade entre 40 e 90 anos ou mais).

Métodos.

Foi realizada uma pesquisa sistemática nas bases de dados Web of Science, MEDLINE, EBSCO, Scopus, SciELO e LILACS (Latin American and Caribbean Health Sciences Literature) para estudos publicados até setembro de 2021. Os termos de busca incluíram uma combinação de termos como “saúde sexual” ou sexualidade” e ”bem-estar”, e termos relacionados às medidas que avaliam os construtos de interesse. A revisão sistemática seguiu as diretrizes PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Os resultados foram agrupados em quatro categorias de avaliação da interação entre saúde sexual e bem-estar subjetivo: fatores cognitivos e atitudinais, comportamento sexual, função sexual e satisfação sexual. Os domínios de bem-estar subjetivo analisados foram satisfação com a vida, afeto positivo e negativo, e bem-estar psicológico.

Resultados.

Foram revisados 15 estudos quantitativos, sendo 14 artigos e uma tese de doutorado. Os resultados sugerem que viver uma vida sexual plena é uma parte essencial do bem-estar subjetivo.

Conclusões.

Esta revisão sugere que os programas destinados a promover bem-estar nas faixas etárias mais velhas também devem incentivar uma vida sexual plena.

Palavras-chave
Envelhecimento; sexualidade; saúde sexual; satisfação pessoal

Subjective well-being is defined as “all of the various types of evaluations, both positive and negative, that people make of their lives. It includes reflective cognitive evaluations, such as life satisfaction and work satisfaction, interest and engagement, and affective reactions to life events, such as joy and sadness” (¹1. Diener E. Guidelines for national indicators of subjective well-being and ill-being. Appl Res Qual Life. 2006;1:151-7.). The World Health Organization (WHO) and the World Association for Sexual Health acknowledge the important positive influences of fulfilling sexual experiences on well-being throughout the life span, including at older ages (²2. World Association for Sexual Health. Declaration of sexual rights [Internet]. Minneapolis (MN): World Association for Sexual Health; 2008 [cited 2021 September 12]. Available from: https://worldsexualhealth.net/resources/declaration-of-sexual-rights/
https://worldsexualhealth.net/resources/... , ³3. World Health Organization. Sexual health, human rights and the law. Geneva: World Health Organization; 2015. https://apps.who.int/iris/handle/10665/175556
https://apps.who.int/iris/handle/10665/1... ). Research suggests that sustained sexual desire and being sexually satisfied may contribute to successful aging (⁴4. Štulhofer AH, Hinchliff S, Jurin T, Carvalheira A, Træen B. Successful aging, change in sexual interest and sexual satisfaction in couples from four European Countries. Eur J Ageing. 2019;16(2):155-65., ⁵5. Štulhofer AH, Hinchliff S, Jurin T, Hald GM, Træen B. Successful aging and changes in sexual interest and enjoyment among older European men and women. J Sex Med. 2018;15(10):1393-402.). Older people not only regard sexuality as an important component of their individual well-being (⁶6. Bauer MH, Haesler E, Fetherstonhaugh D. Let’s talk about sex: older people’s views on the recognition of sexuality and sexual health in the health-care setting. Health Expect. 2016;19(6):1237-50.) but also sexual expression in older age may be beneficial to physical and mental health (⁷7. Fisher L, Anderson GO, Chapagain M, Montenegro X, Smoot J, Takalkar A. Sex, romance, and relationships: AARP survey of midlife and older adults. Washington (DC): AARP; 2010.).

Additionally, subjective well-being potentially acts as a health-protective factor (⁸8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;385(9968):640-8., ⁹9. Lyubomirsky S, King L, Diener E. The benefits of frequent positive affect: does happiness lead to success? Psychol Bull. 2005;131(6):803-55.). The appraisal of one’s subjective well-being has become a key topic in public policy, with improving a population’s well-being emerging as an important societal goal (⁸8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;385(9968):640-8.). Research suggests that well-being is particularly important because pleasant experiences, life satisfaction and psychological well-being are related to health and quality of life as people get older (⁸8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;385(9968):640-8.). Despite the relevance of sexuality in older age, there is a lack of systematic research about how sexual health indicators – such as sexuality-related beliefs and attitudes, sexual behavior, sexual function and sexual satisfaction – are associated with subjective well-being. For the purpose of this review, subjective well-being comprises three concepts: evaluative well-being (i.e. an appraisal of whether people are satisfied with their life), hedonic well-being (i.e. feelings such as happiness or sadness) and eudaimonic well-being (i.e. meaning and purpose in life) as proposed by the Organisation for Economic Co-operation and Development’s guidelines on measuring subjective well-being (¹⁰10. Organisation for Economic Co-operation and Development. OECD guidelines on measuring subjective well-being. Paris: OECD; 2013.).

In parallel, sexual health is regarded as “a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence” (¹¹11. World Health Organization. Defining sexual health: report of a technical consultation on sexual health. Geneva: World Health Organization; 2006.).

Considering that promoting subjective well-being is emerging as an important societal goal (⁸8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;385(9968):640-8.) and research indicates that maintaining a fulfilling sexual life has a positive effect on aging (⁴4. Štulhofer AH, Hinchliff S, Jurin T, Carvalheira A, Træen B. Successful aging, change in sexual interest and sexual satisfaction in couples from four European Countries. Eur J Ageing. 2019;16(2):155-65., ⁵5. Štulhofer AH, Hinchliff S, Jurin T, Hald GM, Træen B. Successful aging and changes in sexual interest and enjoyment among older European men and women. J Sex Med. 2018;15(10):1393-402.) and health (⁷7. Fisher L, Anderson GO, Chapagain M, Montenegro X, Smoot J, Takalkar A. Sex, romance, and relationships: AARP survey of midlife and older adults. Washington (DC): AARP; 2010.), this systematic review aimed at verifying whether current research answers the following question: Is there a link between sexual health indicators and subjective well-being in older age groups?

METHODS

Data search

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (¹²12. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264-9.).

The literature search was conducted in September 2021 using the Web of Science, MEDLINE (PubMed), EBSCO (APA PsycARTICLES and APA PsycInfo), Scopus, SciELO and LILACS (Latin American and Caribbean Health Sciences Literature) databases. Different combinations of search strings were used to increase the number of potential records retrieved. Results were not restricted by year of publication.

The search was conducted using the following strings: (i) well-being AND (“sexual health” OR sexuality OR “sexual well-being”) AND (aging OR ageing OR elderly OR “older adults” OR seniors OR geriatrics); (ii) (“satisfaction with life” OR “positive affect” OR “negative affect”) AND (“sexual health” OR sexuality OR “sexual well-being”) AND (aging OR ageing OR elderly OR “older adults” OR seniors OR geriatrics); (iii) well-being AND (GMSEX OR “Global Measure of Sexual Satisfaction” OR SPS OR “Sexual Pleasure Scale” OR NSSS OR “New Sexual Satisfaction Scale” OR ISS OR “Index of Sexual Satisfaction” OR “sexual well-being”) AND (aging OR ageing OR elderly OR “older adults” OR seniors OR geriatrics) AND sexual* AND (function* OR dysfunction*); (iv) (SWLS OR “Satisfaction with Life Scale” OR PANAS OR “Positive and Negative Affect Schedule”) AND (“sexual health” OR sexuality OR “sexual well-being”) AND (aging OR ageing OR elderly OR “older adults” OR seniors OR geriatrics) and (v) (SWLS OR “Satisfaction with Life Scale” OR PANAS OR “positive and negative affect schedule”) AND (GMSEX OR “Global Measure of Sexual Satisfaction” OR SPS OR “Sexual Pleasure Scale” OR NSSS OR “New Sexual Satisfaction Scale” OR ISS OR “Index of Sexual Satisfaction” OR “sexual well-being”) AND (aging OR ageing OR elderly OR "older adults" OR seniors OR geriatrics).

Eligibility criteria

Studies were eligible for inclusion if their sample included participants aged ≥65 years or participants’ mean age was >60 years or analyses were stratified by age; they had an assessment of sexual health (e.g. sexual function, sexual behavior, sexual satisfaction, sexual well-being); subjective well-being was assessed using a validated measure; and the data analysis tested a statistical association between sexual health and subjective well-being. Studies were excluded if they used a nonquantitative evaluation of the dimensions of sexual health and well-being or they were not an original study (e.g. if the study was a review or unpublished dissertation) written in English, Portuguese or Spanish.

Study selection and analysis

After the data search was completed and duplicate records were eliminated, the search results were downloaded into a Rayyan database (https://www.rayyan.ai/). The first author (PV) performed the initial screening based on the title, abstract and full text of the document to identify papers that examined indicators of sexual health and subjective well-being. When required, the coauthors (CP, SJS, RG and PN) judged whether to select or discard a paper and resolved any disagreements about inclusion.

Information relevant to conducting a narrative synthesis of the results was retrieved from the studies that fulfilled the eligibility criteria. Specifically, studies were coded according to the year of publication, country where the study was conducted, sample characteristics (e.g. age and gender of participants), study design and the assessment methodology used for both the sexual health and subjective well-being domains.

RESULTS

A total of 20 812 publications were identified. One additional publication was retrieved through a manual search of the reference lists. After duplicates were removed, 15 301 records remained to be screened based on their title; 357 records were screened based on their abstract; and 51 of these were included in the full-text screening. The full-text screening of potentially relevant articles assessed against the eligibility criteria resulted in a total of 15 included studies. Figure 1 illustrates the process of data screening and study selection.

All studies included in the review provided quantitative analyses. Sexual diversity was not explicitly defined as an exclusion criterion for study selection, but no information about its assessment was identified in the included studies.

The 15 studies that examined sexual health and subjective well-being in older age groups used a variety of scales and some used more than one: 6 studies used the Satisfaction with Life Scale (¹³13. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With Life Scale. J Pers Assess. 1985;49(1):71-5.), 6 used the Center for Epidemiologic Studies Depression Scale (¹⁴14. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas.1977;1(3):385-401.), 2 used Cantril’s Ladder (¹⁵15. Cantril H. The pattern of human concerns. New Brunswick (NJ): Rutgers University Press; 1966.), 1 used the Life Satisfaction Index-A (¹⁶16. Neugarten BL, Havighurst RJ, Tobin SS. The measurement of life satisfaction. J Gerontol. 1961;16:134-43.), 1 used the Positive and Negative Affect Schedule (PANAS) (¹⁷17. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol. 1988;54(6):1063-70.), 1 used the Ryff Scales of Psychological Wellbeing (¹⁸18. Ryff CD, Keyes CLM. The structure of psychological well-being revisited. J Pers Soc Psychol. 1995;69(4):719-27.), and 2 studies used other measures. Study characteristics are described in Table 1.

Main findings

Results from the studies included in this review suggest that sexual health is significantly linked with subjective well-being in older age groups. The findings can be grouped into four categories: (i) studies concerning cognitive and attitudinal factors related to sexuality and subjective well-being, (ii) studies concerning sexual behavior and subjective well-being, (iii) studies concerning sexual function and subjective well-being and (iv) studies concerning sexual satisfaction and subjective well-being. Results are discussed separately by category

Cognitive factors and subjective well-being

In a study of men aged between 70 and 94 years, participants answered the question “How important is sex in your life now?” (¹⁹19. Thomas LE. Correlates of sexual interest among elderly men. Psychol Rep. 1991;68(2):620-2.). Most indicated that sex was no longer important, with a minority of participants stating that sex still remained a very important aspect of their lives. These results varied by age, with younger participants tending to report that sex was more important than the older participants did. Regarding the relationship between importance of sexuality and life satisfaction, results pointed to the absence of a significant association (P > 0.05) (¹⁹19. Thomas LE. Correlates of sexual interest among elderly men. Psychol Rep. 1991;68(2):620-2.).

Research looking at the role of sexual attitudes and knowledge about sexuality on life satisfaction in men and women aged >65 years revealed that sexual attitudes were more positive among younger participants, and among those who had a high school degree or higher educational level and among those who lived with their partner. The same applied to knowledge about sexuality: scores were higher for these same groups of participants, particularly for men (²⁰20. Park HK, Kang SK, Park S. Sexual knowledge, sexual attitude, and life satisfaction among Korean older adults: implications for educational programs. Sex Disabil. 2016;34(4):455-68.).

In terms of the relationship between sexual attitudes and knowledge and life satisfaction, there were significant associations between sexual attitudes and life satisfaction (r = 0.121, P < 0.01) and between knowledge about sexuality and life satisfaction (r = 0.144, P < 0.01) (²⁰20. Park HK, Kang SK, Park S. Sexual knowledge, sexual attitude, and life satisfaction among Korean older adults: implications for educational programs. Sex Disabil. 2016;34(4):455-68.).

Sexual attitudes and knowledge emerged as significant dimensions when analyzing the predictive value of different factors on older adults’ life satisfaction. In the general model, for both men and women sexual knowledge had a significant association with life satisfaction (β = 0.11, t = 2.17, P < 0.05). When accounting for gender differences, results indicated that for men sexual attitudes significantly predicted life satisfaction (β = 0.16, P < 0.05), while for women sexual knowledge emerged as a determining factor (β = 0.17, P < 0.01) (²⁰20. Park HK, Kang SK, Park S. Sexual knowledge, sexual attitude, and life satisfaction among Korean older adults: implications for educational programs. Sex Disabil. 2016;34(4):455-68.).

Sexual behavior and subjective well-being

A portion of studies included in this review analyzed the association between the frequency of sexual activity and subjective well-being. Of the seven studies that addressed sexual behavior and frequency of sexual activity, only one did not provide a definition of sexual activity, instead measuring the frequency of sexual activity by using the question, “During the past 12 months, about how often did you have sex with your spouse or partner?” (²¹21. Eckhouse CM. Transition to old age: how do sexual behaviors and personality contribute to successful aging [dissertation]? Washington (DC): George Washington University; 2018.). Most studies provided a description of sexual activity or listed different sexual activities, including or differentiating physical tenderness (e.g. fondling, caressing, kissing).

In a community-based study, Skałacka and Gerymski (²²22. Skałacka KG, Gerymski R. Sexual activity and life satisfaction in older adults. Psychogeriatrics. 2019;19(3):195-201.) showed that not only was the frequency of sexual activity (rs = 0.44, P < 0.05) linked with life satisfaction but the variety of sexual behaviors (rs = 0.43, P < 0.05) was also linked. Freak-Poli and colleagues (²³23. Freak-Poli R, Lima GDC, Direk N, Jaspers L, Pitts M, Hofman A, et al. Happiness, rather than depression, is associated with sexual behaviour in partnered older adults. Age Ageing. 2017;46(1): 101-7.) showed that after controlling for a set of demographic and health-related covariates, the frequency of sexual activity was linked with life satisfaction in partnered participants (P < 0.001). For unpartnered participants, physical tenderness was linked with life satisfaction (P < 0.05) (²³23. Freak-Poli R, Lima GDC, Direk N, Jaspers L, Pitts M, Hofman A, et al. Happiness, rather than depression, is associated with sexual behaviour in partnered older adults. Age Ageing. 2017;46(1): 101-7.). A study that stratified analyses by gender and age highlighted that a 1-year decline in the frequency of sexual activity negatively affected life satisfaction in women (P < 0.001) aged 60–69 years (F_{1, 897} = 5.57, P = 0.019) (²⁴24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7.). In a population-based study, women (b = −1.14, P < 0.01) and men (b = −1.00, P < 0.05) who indicated they had infrequent sexual activity or no sexual activity during the past month had less satisfaction with life (²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710.).

In terms of the interplay between sexual behavior and affect, the frequency of sexual activity was linked with positive affect (P < 0.001) (²³23. Freak-Poli R, Lima GDC, Direk N, Jaspers L, Pitts M, Hofman A, et al. Happiness, rather than depression, is associated with sexual behaviour in partnered older adults. Age Ageing. 2017;46(1): 101-7.). A 1-year decline in the frequency of sexual activity was linked with negative affect in both men and women (P < 0.001) (²⁴24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7.). A nationally representative study that stratified analyses by age found that for both men (F_{7, 912} = 5.89, P <0.001, R2 = 0.04) and women (F_{7, 858} = 8.03, P < 0.001, R2 = 0.06), the frequency of sexual activity is positively linked with happiness when compared with results from a younger age group (²⁶26. Karraker A, DeLamater J, Schwartz CR. Sexual frequency decline from midlife to later life. J Gerontol B Psychol Sci Soc Sci. 2011;66(4):502-12.). In a population-based dyadic study that focused on the influence of a specific sexual behavior, receiving oral sex was linked with positive affect through the respondent’s appraisal of relationship quality (²⁷27. Liu H, Shen S, Hsieh N. A national dyadic study of oral sex, relationship quality, and well-being among older couples. J Gerontol B Psychol Sci Soc Sci. 2019;74(2):298-308.). Specifically, when the female partner reported higher levels of relationship quality, she and her male partner were more likely to be happier (β = 0.482, P < 0.001 for the effect on the actor; and β = 0.085, P < 0.05 for the effect on the partner) (²⁷27. Liu H, Shen S, Hsieh N. A national dyadic study of oral sex, relationship quality, and well-being among older couples. J Gerontol B Psychol Sci Soc Sci. 2019;74(2):298-308.). In contrast, when the male partner indicated a higher-quality relationship, he was more likely to report higher levels of happiness (β = 0.365, P < 0.001), but his partner was not (²⁷27. Liu H, Shen S, Hsieh N. A national dyadic study of oral sex, relationship quality, and well-being among older couples. J Gerontol B Psychol Sci Soc Sci. 2019;74(2):298-308.).

Only one study addressed the relationship between sexual behavior and eudaimonic subjective well-being (²¹21. Eckhouse CM. Transition to old age: how do sexual behaviors and personality contribute to successful aging [dissertation]? Washington (DC): George Washington University; 2018.). Results indicated that the frequency of sexual activity added to the prediction of change in psychological well-being (R2 change = 0.002, P = 0.03). However, including the frequency of sexual activity did not increase the variance explained in psychological well-being (²¹21. Eckhouse CM. Transition to old age: how do sexual behaviors and personality contribute to successful aging [dissertation]? Washington (DC): George Washington University; 2018.).

Sexual function and subjective well-being

This review found relationships between sexual function and subjective well-being in older age. A population-based study found a significant association between sexual desire and life satisfaction in men (P = 0.012), suggesting that men who had reduced sexual desire also reported lower life satisfaction (²⁴24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7.). Lee and colleagues (²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710.) found a consistent pattern of associations between sexual function and life satisfaction among women. For instance, women with difficulties in arousal and desire were more prone to report lower levels of life satisfaction (b = −1.14, P < 0.01). By comparing men with and without declines in sexual function, a study revealed that men with erectile or orgasmic complaints reported being less satisfied with their life (P < 0.001) (²⁸28. Lu Y, Fan S, Cui J, Yang Y, Song Y, Kang J, et al. The decline in sexual function, psychological disorders (anxiety and depression) and life satisfaction in older men: a cross-sectional study in a hospital-based population. Andrologia. 2020;52(5):e13559.).

Findings also suggested an association between sexual function and affect. Both men and women who reported a loss of sexual desire tended to have higher levels of negative affect (P = 0.001) (²⁴24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7.). Results from a study of partnered older adults pointed out that men with orgasmic difficulties (b = 0.25, P < 0.05) or severe complaints about orgasmic and erectile dysfunction (b = 0.41, P < 0.001) had higher levels of negative affect, regardless of their frequency of sexual activity (²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710.). In a different study, Lee and coauthors also found evidence of an interplay between erectile difficulties and negative affect, even after controlling for the effects of age and self-rated health [Exp(B) = 2.71 (95% confidence interval [CI]: 1.38 to 5.34, P < 0.01] (²⁹29. Lee DM, Nazroo J, O’Connor DB, Blake M, Pendleton N. Sexual health and well-being among older men and women in England: findings from the English Longitudinal Study of Ageing. Arch Sex Behav. 2016;45(1):133-44.). For women, having a medium level of sexual desire and a low frequency of sexual activity was linked with negative affect (b = 0.44, P < 0.01) (²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710.).

Sexual satisfaction and subjective well-being

A set of studies included in this review examined the associations between sexual satisfaction and subjective well-being. Findings from a cross-sectional study suggested that sexual satisfaction is positively correlated with life satisfaction (rs = 0.55, P < 0.05) (²²22. Skałacka KG, Gerymski R. Sexual activity and life satisfaction in older adults. Psychogeriatrics. 2019;19(3):195-201.). Prospective research supports these results: a prospective study on the predictors of life satisfaction among retired physicians and their spouses found that increased sexual satisfaction after retirement was related to higher levels of life satisfaction [Exp(B) = 1.45 (95% CI: 1.09 to 1.94), P < 0.05] (³⁰30. Austrom MG, Perkins AJ, Damush TM, Hendrie HC. Predictors of life satisfaction in retired physicians and spouses. Soc Psychiatry Psychiatr Epidemiol. 2003;38(3):134-41.). Similarly, a longitudinal population-based study showed that for both men and women sexual satisfaction predicted life satisfaction (β = 0.08, P < 0.001) (³¹31. Buczak-Stec E, Hans-Helmut K, Hajek A. The link between sexual satisfaction and subjective well-being: a longitudinal perspective based on the German Ageing Survey. Qual Life Res. 2019;28(11):3025-35.). In contrast, a different prospective study with a nationally representative sample that stratified analyses by age revealed gender differences in how sexual satisfaction influenced life satisfaction. For men, results were consistent with the preceding findings, since sexual satisfaction was linked with life satisfaction (β_FE = 0.14, P < 0.001). For women, sexual satisfaction was not relevant to their overall satisfaction with life (β_FE = 0.09, P > 0.05) (³²32. Schafer MH, Mustillo SA, Ferraro KF. Age and the tenses of life satisfaction. J Gerontol B Psychol Sci Soc Sci. 2013;68(4):571-9.).

A significant association between sexual satisfaction and positive affect (β = 0.04, P < 0.001) was found (³¹31. Buczak-Stec E, Hans-Helmut K, Hajek A. The link between sexual satisfaction and subjective well-being: a longitudinal perspective based on the German Ageing Survey. Qual Life Res. 2019;28(11):3025-35.). Sexual satisfaction was also linked with negative affect but only for men (β = −0.04, P < 0.05) (³¹31. Buczak-Stec E, Hans-Helmut K, Hajek A. The link between sexual satisfaction and subjective well-being: a longitudinal perspective based on the German Ageing Survey. Qual Life Res. 2019;28(11):3025-35.). A negative correlation between sexual satisfaction and negative affect was also found for both men and women in a community-based study (t = −2.88, P <0.01) (³³33. Thompson WK, Charo L, Vahia IV, Depp C, Allison M, Jeste DV. Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women. J Am Geriatr Soc. 2011;59(8):1503-8.).

One study analyzed the predictive role of sexual satisfaction on eudaimonic subjective well-being. Results suggested that sexual satisfaction is a determining factor for psychological well-being (R² change = 0.02, P < 0.001), explaining an additional 3% of variance (²¹21. Eckhouse CM. Transition to old age: how do sexual behaviors and personality contribute to successful aging [dissertation]? Washington (DC): George Washington University; 2018.).

DISCUSSION

This review focuses on an essential but overlooked area of health care: sexuality and sexual health in older age groups and their associations with subjective well-being. This review sought to determine whether there is a link between indicators of sexual health and subjective well-being; the studies included in this review suggest that different indicators of sexual health are markers for factors of subjective well-being in older age groups. Even though two studies found no significant correlations between the importance of sexuality (¹⁹19. Thomas LE. Correlates of sexual interest among elderly men. Psychol Rep. 1991;68(2):620-2.) or sexual satisfaction (³²32. Schafer MH, Mustillo SA, Ferraro KF. Age and the tenses of life satisfaction. J Gerontol B Psychol Sci Soc Sci. 2013;68(4):571-9.) and life satisfaction, the remaining studies consistently revealed significant associations between sexual health and subjective well-being.

More specifically, maintaining an active, satisfying and fulfilling sexual life as people age is positively linked with life satisfaction (²²22. Skałacka KG, Gerymski R. Sexual activity and life satisfaction in older adults. Psychogeriatrics. 2019;19(3):195-201.

23. Freak-Poli R, Lima GDC, Direk N, Jaspers L, Pitts M, Hofman A, et al. Happiness, rather than depression, is associated with sexual behaviour in partnered older adults. Age Ageing. 2017;46(1): 101-7.

24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7.-²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710., ³⁰30. Austrom MG, Perkins AJ, Damush TM, Hendrie HC. Predictors of life satisfaction in retired physicians and spouses. Soc Psychiatry Psychiatr Epidemiol. 2003;38(3):134-41., ³¹31. Buczak-Stec E, Hans-Helmut K, Hajek A. The link between sexual satisfaction and subjective well-being: a longitudinal perspective based on the German Ageing Survey. Qual Life Res. 2019;28(11):3025-35., ³³33. Thompson WK, Charo L, Vahia IV, Depp C, Allison M, Jeste DV. Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women. J Am Geriatr Soc. 2011;59(8):1503-8.). Negative mood or affect appears to be associated with a lower frequency of sexual activities, having more sexual complaints and lower sexual satisfaction (²⁴24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7., ²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710., ²⁷27. Liu H, Shen S, Hsieh N. A national dyadic study of oral sex, relationship quality, and well-being among older couples. J Gerontol B Psychol Sci Soc Sci. 2019;74(2):298-308., ³³33. Thompson WK, Charo L, Vahia IV, Depp C, Allison M, Jeste DV. Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women. J Am Geriatr Soc. 2011;59(8):1503-8.), but positive states are related to engaging in diverse sexual interactions (²³23. Freak-Poli R, Lima GDC, Direk N, Jaspers L, Pitts M, Hofman A, et al. Happiness, rather than depression, is associated with sexual behaviour in partnered older adults. Age Ageing. 2017;46(1): 101-7., ²⁶26. Karraker A, DeLamater J, Schwartz CR. Sexual frequency decline from midlife to later life. J Gerontol B Psychol Sci Soc Sci. 2011;66(4):502-12., ²⁷27. Liu H, Shen S, Hsieh N. A national dyadic study of oral sex, relationship quality, and well-being among older couples. J Gerontol B Psychol Sci Soc Sci. 2019;74(2):298-308.). In the interplay between sexual health–related cognitions and attitudes and subjective well-being, findings point out that having a more positive attitude towards sexual expression in older age and being aware of how sexuality may change with age might contribute to life satisfaction (²⁰20. Park HK, Kang SK, Park S. Sexual knowledge, sexual attitude, and life satisfaction among Korean older adults: implications for educational programs. Sex Disabil. 2016;34(4):455-68.). A particularly interesting finding was that eudaimonic well-being was predicted only by sexual satisfaction rather than the frequency of sexual activity (²¹21. Eckhouse CM. Transition to old age: how do sexual behaviors and personality contribute to successful aging [dissertation]? Washington (DC): George Washington University; 2018.). Such results highlight the importance of having a positive approach towards sexuality in older age. For instance, WHO’s definition of sexual health (¹¹11. World Health Organization. Defining sexual health: report of a technical consultation on sexual health. Geneva: World Health Organization; 2006.) suggests focusing on well-being in relation to sexuality instead of on the absence of sexual dysfunction (³⁴34. Syme ML, Cohn TJ, Stoffregen S, Kaempfe H, Schippers D. “At my age … ”: defining sexual wellness in mid- and later life. J Sex Res. 2019;56(7):832-42.).

Finally, a note on the existing literature. Studies included in this review consider older age groups rather than exclusively analyzing relationships between these domains in the older population (aged > 65 years). Although prospective and population-based studies were identified (²¹21. Eckhouse CM. Transition to old age: how do sexual behaviors and personality contribute to successful aging [dissertation]? Washington (DC): George Washington University; 2018., ²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710.

26. Karraker A, DeLamater J, Schwartz CR. Sexual frequency decline from midlife to later life. J Gerontol B Psychol Sci Soc Sci. 2011;66(4):502-12.-²⁷27. Liu H, Shen S, Hsieh N. A national dyadic study of oral sex, relationship quality, and well-being among older couples. J Gerontol B Psychol Sci Soc Sci. 2019;74(2):298-308., ²⁹29. Lee DM, Nazroo J, O’Connor DB, Blake M, Pendleton N. Sexual health and well-being among older men and women in England: findings from the English Longitudinal Study of Ageing. Arch Sex Behav. 2016;45(1):133-44., ³¹31. Buczak-Stec E, Hans-Helmut K, Hajek A. The link between sexual satisfaction and subjective well-being: a longitudinal perspective based on the German Ageing Survey. Qual Life Res. 2019;28(11):3025-35., ³²32. Schafer MH, Mustillo SA, Ferraro KF. Age and the tenses of life satisfaction. J Gerontol B Psychol Sci Soc Sci. 2013;68(4):571-9.), research that addresses sexual health and subjective well-being in older people was mostly cross-sectional. This review showed that there are few studies focusing on this association among older people. This is particularly noticeable in the lack of studies that include sexually diverse older populations and the lack of studies conducted in low- and middle-income countries. The use of different measures to assess sexuality and the subjective well-being domains limits the conclusions that can be drawn from the studies. Further research should focus on the underlying mechanisms that contribute to maintaining and achieving sexual health in older age, and differences that influence subjective well-being. Cohort studies can clarify how sexual health changes as people age and to what extent these changes impact subjective well-being while accounting for potential generational effects, as well as for change and stability in sexual and well-being outcomes. Dyadic studies can contribute to understanding how differences and similarities between older partners’ sexual health indicators interact with different domains of subjective well-being. Analyzing the interplay between these domains in sexually diverse groups of older adults can shed light on how these domains relate to one another, providing representative findings on the relationship between sexual health and subjective well-being in older people.

Notwithstanding, there are some limitations to our review. The first consists of the exclusion of other components of well-being. Subjective well-being is one of many components of wellness (⁸8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;385(9968):640-8.). The exclusion of other dimensions, such as quality of life or physical and mental health, may have limited not only the number of studies included in this review but also the drawing of more complex conclusions. Moreover, even when studies were longitudinal and population-based, they were mostly correlational, which limits our ability to establish causal associations. This is particularly evident in studies looking at the interplay between sexual function and subjective well-being (²⁴24. Jackson SE, Firth J, Veronese N, Stubbs B, Koyanagi A, Yang L, et al. Decline in sexuality and wellbeing in older adults: a population-based study. J Affect Disord. 2019;245:912-7., ²⁵25. Lee DM, Vanhoutte B, Nazroo J, Pendleton N. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol B Psychol Sci Soc Sci. 2016;71(4):698-710., ²⁸28. Lu Y, Fan S, Cui J, Yang Y, Song Y, Kang J, et al. The decline in sexual function, psychological disorders (anxiety and depression) and life satisfaction in older men: a cross-sectional study in a hospital-based population. Andrologia. 2020;52(5):e13559., ²⁹29. Lee DM, Nazroo J, O’Connor DB, Blake M, Pendleton N. Sexual health and well-being among older men and women in England: findings from the English Longitudinal Study of Ageing. Arch Sex Behav. 2016;45(1):133-44.). The absence of a temporal relationship between variables makes it difficult to establish sexual function as a cause of different levels of subjective well-being – that is, this relationship might work in the opposite direction, with sexual complaints emerging as a result of variations in life satisfaction or affect.

Even so, to the best of our knowledge, this is the first systematic review that specifically focuses on indicators of sexual health and their interplay with subjective well-being in older age groups. A major concern in public health is how to maintain and promote people’s well-being as they age (⁸8. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015;385(9968):640-8.). Also, person-centered approaches are preferred for monitoring and assessing worldwide outcomes, as well as informing global health policy-making (³⁵35. Skevington SM, Epton T. How will the Sustainable Development Goals deliver changes in well-being? A systematic review and meta-analysis to investigate whether WHOQOL-BREF scores respond to change. BMJ Glob Health. 2018;3 Suppl 1:e000609.). Thus, systematizing evidence on the relationship between sexual health and subjective well-being in later life has become particularly relevant.

Conclusions

The aim of this systematic review was to determine whether current research answers the following question: Is there a link between sexual health indicators and subjective well-being in older age groups? Current research on the relationship between sexual health and subjective well-being in older age groups suggests that living a fulfilling sexual life is an essential part of subjective well-being. Nonetheless, additional evidence is required to understand how sexual health affects subjective well-being in older age in a more generalizable manner, including among those aged >65 years and sexually diverse. As global health policy prioritizes the relevance of promoting well-being in older age by implementing a person-centered approach, the inclusion of sexual health as an intervention tool may be particularly relevant. In conclusion, findings from this review suggest that programs that aim at promoting well-being may benefit from encouraging a fulfilling sexual life in older age.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health or those of the Pan American Health Organization (PAHO).

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