Silvia Montoya is a 35-year-old gynecologist who routinely performs reconstructive surgery on older women suffering, for example, from prolapse, a condition brought on when the pelvic floor collapses as a result of childbirth, and which was rarely treated even a generation ago.
Like most men and women of her age, Montoya had always assumed that the elderly have no interest in, and much less ability to physically enjoy, sex.
She tells the story of how her eyes were opened to the reality of sex after sixty.
"I was talking to an 80-year-old lady on whom I was about to perform a prolapse operation, and she asked me if I would be carrying out the operation. I said that I was, and reassured her that everything would be fine. "Then the woman said: 'I want to be sure that you are going to leave everything in good order down there; I have a friend in the retirement home, and I don't want any loss of sensation, if you know what I mean'."
Most surgeons assume that elderly women no longer have sex
One doctor told a female patient in her fifties: "nature has finished with you"
Of Spain's 44 million people, more than eight million are over 65
Over the last 20 years, the Spanish family structure has changed rapidly
Montoya says that she didn't immediately pick up on what the woman was saying. Then, after a couple of seconds, she says that it dawned on her: "Don't worry, we'll leave you feeling better than ever, and with everything in full working order."
Montoya says that in the case of prolapse operations in older women, the entrance to the vagina is often stitched up to the point where penetration is no longer possible.
"Most surgeons assume that elderly women no longer have sex, and that this practice is not an issue. But I learned a lesson that day. Her uterus had been protruding from the vaginal canal for years. She was a widow, but had met somebody, and decided that she wanted to have sexual relations. I was very moved by the experience, and I have to say that I really excelled that day in the operating theater."
We like to think that we live in more enlightened times: that 50 is the new 40; that 60 is the new 50; and that 70 is the new 60 - except when it comes to sex, which somehow tastefully disappears from our lives once we pass 60.
Old folks are supposed to be genderless folks. As one doctor less-than-tactfully put it to a female patient in her fifties: "nature has finished with you." A generation on from the supposed sexual revolution of the 1960s - which didn't reach Spain until a decade later - whether we like to admit it or not, most of us still assume that once the reproductive cycle is over, we return to an infantile state from the waist down. Tenderness, sure; even flirtation: but not predatory.
The image of an elderly couple out for a walk, hand in hand, or maybe chastely embraced in a gentle two-step at a village dance brings a warming smile to our faces. But the thought of passionate kissing, of intimate caresses, or of the pleasurable moans that precede orgasm is more likely to make us wrinkle our noses. We either assume it's just not physically possible, or wouldn't occur to any right-thinking retiree, or is just plain bad taste. Hence the expression dirty old man.
Sex in old age is one of the last taboos, despite the fact that we live in an ageing society: of Spain's 44 million inhabitants, there are more than eight million people aged over 65. And 28 percent of those are over 80. More than half still live with their partner, but in a country where women outlive men by nearly seven years, dying on average at 84 years of age, 38 percent are widows.
It is interesting to note that the latest report by Imserso, the state-run body that cares for the elderly, makes no mention of sexual habits among the over 60s. Similarly, a government survey on sexual habits carried out last year dedicates very little space to its "65+" category. As with so many other examples of their needs, demographers and politicians are not interested in the sexual wellbeing of the over-65s.
But according to a study by the state-funded Family Medicine Society, around 60 percent of over-65s say that they enjoy a good sex life, engaging in intercourse around four times a month. The other 40 percent say that they have a range of practical, physiological, or psychological problems that prevent them from enjoying sex, or have simply given up on it. In many cases, it is simply because their partner has died, or they are divorced.
As a result of Spain's demographics, there are more sexually inactive women over the age of 60 than men. That said, Spain's situation pretty much matches the figures that emerged from a survey carried out by the prestigious New England Journal of Medicine in 2008. The survey reported that 73 percent of Americans aged between 57 and 64 enjoyed a regular sex life. The figure dropped to 53 percent between the 65 and 75-year-old age group, and fell more sharply to 26 percent among 85-year-olds. "Even so," write the authors in their conclusion, "there is a significant number of people who have vaginal intercourse, oral sex, or continue to masturbate even into their nineties."
None of which is to say that our sex lives don't change and to varying degrees diminish as we get older, in large part due to physiological factors. Women's estrogen levels can drop significantly with menopause, provoking vaginal dryness; at the same time, diminished blood flow to the genitals can also reduce desire, explains gynecologist Santiago Palacios, president of the Spanish Menopause Society.
Hormonal factors are not so important in men, although their testosterone levels do drop. Physical deterioration, heart disease, high blood pressure and diabetes can also reduce the ability to gain or maintain an erection, and there is a general lessening of the libido, says Eduardo Ruiz Castañe, head of the andrology department at the Puigvert Foundation, a Barcelona-based non-profit body dedicated to research into male urological and genital pathologies.
But in both sexes, overall health, the quality of sex earlier in life, good communication with one's partner and being able to find the time and place to be intimate are more important factors than the mere ageing process. Both Palacios and Ruiz Castañe agree that our sexuality changes over the years - and will likely diminish - but we remain sexual beings until the moment that life itself ends.
Fina and Joan, aged 79 and 85 respectively, have been married for 57 years. Very much the typical elderly couple, they say that they still enjoy sexual relations every Saturday "as a rule" and, if they feel like it, will indulge themselves midweek. They both enjoy good health, although Joan has mild diabetes and Fina suffers from slight arthritis. They say that they were both virgins when they married, and subsequently had three children, never using any form of contraception other than withdrawal.
Ten years ago, "so as not to be a burden on the kids," they sold their apartment in Barcelona and moved into one of the many private retirement homes that have sprung up along the Mediterranean coast near the Catalan capital.
They are far from alone in taking this option. Over the last 20 years, the Spanish family structure has changed rapidly. Once a society where the elderly were looked after by their children, either living with them or close by, Spanish families have increasingly become nuclear in structure, along the lines of those in northern Europe and the United States.
At the same time, a generation, to which Joan and Fina belong, has emerged that does not want to live with their children, preferring instead to pay for private care, either at home or in a retirement home. As Fina admits, it's not just a question of "not being a burden" to their children; they also want their privacy.
The couple has a spacious, 20-square-meter bedroom in a private retirement home. They eat and socialize with the rest of the guests, but spend a large part of their time in their room, which has a balcony, and a bed that seems to take up more than half the space.
"We have had some lovely times in it," says Fina, preparing a coffee (they are not supposed to have any cooking equipment in their rooms, but have skillfully camouflaged the brand name coffeemaker) and offering her visitors sugar-free pastries. "There are some here who think that sleeping together at our age is wrong, but I have never felt any shame or disgust towards my husband," she adds. "We may not do it as we are supposed to, but we do what we can, so as not to lose one of the greatest pleasures in life," adds Joan. "And I don't believe in Viagra. I may not be what I was, and to be honest, I'm not sure anymore what proper sex really means, but I get by."
Fina clarifies her husband's explanation by adding: "God gave us hands, lips, and the tongue for something. You never know how to start, and much less how it is going to end; sometimes a few tickles and strokes gets things going, and at other times we kiss and hug each other, and that is enough."
Joan and Fina, who have never read any books on sexuality or sexual techniques - "in the old days, nobody ever talked about sex, and I wasn't even taught about my menstrual cycle. But we have picked things up from watching the television, and the odd dirty film that we have rented" - say that they have nevertheless enjoyed a full and satisfying sex life over the years.
"I have to be honest, I enjoy myself more now than I ever did," says Fina. "In the old days he was like a stallion, but it was all over too quickly, and I felt that I needed more time. These days he isn't so strong, but is slower, and that suits me perfectly. In any event, as I have never known another man, I can't really compare," she laughs, looking slyly at her husband, who joins in the laughter.
Joan and Fina's generation have lived through tremendous change, having not only seen their life expectancy increase (Spain's is among the highest in the EU), but, since Spain returned to democracy 35 years ago, the quality of life of the elderly has vastly improved, and as a result, older people no longer think of themselves as, well, old, according to Imserso.
The generation that grew up after the Spanish Civil War faced harsh economic and social conditions. Aside from lack of work and education, and the brutality of the Franco regime, the Joans and Finas were subject to the sexual and moral repression of the Catholic Church.
Sex outside marriage was a sin, although prostitution was rife. The roles of men and women were clear: reproduction was the sole reason for sex, although women were obliged to fulfill their conjugal obligations. Pleasure was not part of the equation.
"Women are no longer resigned to their fate. If they have enjoyed good sex, they want to continue having good sex, and if there is a problem, then they are prepared to ask for help," says gynecologist Santiago Palacios. "At the same time as we are looking into how to improve blood flow, there are already creams and other products to lubricate the vagina, and that also provide a small amount of estrogen, combat dryness, and help people engage in sexual intercourse. Anybody in menopause should use them. I always tell my patients to think in terms of the replenishing and moisturizing creams that they use on their faces throughout their lives," he says.
For men, andrologist Ruiz Castañe says that sildenafil citrate, the active ingredient in Viagra, Cialis, and Levitra, has given millions of elderly men throughout Spain a new lease of their sex life. But he cautions that penetrative sex isn't the only measure of pleasure. "We have to get away from this genital-fixated view of sex. The more varied the sexual practices we indulge in, the more we will enjoy sex when we are older."
That said, for many elderly people, sex still means coitus. José Antonio García is a 73-year-old former mechanic now living in a retirement home in the northeastern city of Zaragoza. While his fellow retirees at the home are probably whiling away the afternoon playing cards, watching daytime television or at best attending the weekly yoga class, he has come to see sexologist Santiago Frago, the founder of the Amaltea Institute, which works for the city authorities, dealing with elderly people's sexual problems.
García has been married for the last half-century to Eufemia Hernández, nine years his senior: "an amazing woman and companion who has never questioned anything I have suggested," he says. "For the first 15 or 20 years we had sex every day, then it dropped down to around twice a week, usually Wednesdays and Saturdays." But he says that over the last year he has started to "droop." The problem, Frago quickly diagnoses, is high blood pressure, along with high levels of uric acid, and cholesterol. "I don't even bother her with it anymore, what's the point? It's just impolite to get her going and then not follow through," says García with disarming frankness.
"How about trying something else, maybe kissing, touching each other," suggests Frago. "No, we're old school. We haven't even bothered to try the other stuff; we're not interested in trying anything new. And I can tell you that I have never wanted another woman, not even if Rita Hayworth had come knocking, or that Beyoncé, who is a stunner," adds García.
"Well, I guess that unless you took something, even if the pair of them came round to your house, you wouldn't be able to get it up," replies Frago in a similarly candid vein.
Frago writes out a prescription for Cialis, suggesting that his patient take two five-milligram tablet two hours before sex, and that the dose will last him for three days. "Let me know how it goes," he says.
After García has left, Frago says that while he and his colleagues try to persuade older people that intercourse is not the only course, "and we have to get away from this genital fixation, there are a lot of men who come here with the sexual habits of a lifetime, and they are not about to change them. And for them, Viagra works wonders. It should be available through the national health system," he says.
Frago says that much more needs to be done by health services to help older people enjoy an active sexual life. He also points out that more and more older people are coming to his clinic expecting help.
"There was a time when we used to think that there was something perverted about older people wanting sex, but we are already seeing people around the age of 60 who still view themselves very much in sexual terms: they have good health, they are sexually experienced, and they want to continue enjoying sex. Many of them have had to overcome the repressive sexual mores of the old days," he says.
What's more, growing numbers of older people are getting divorced, and want to be able to have sexual relations with their new partners. In 2008, 13,000 Spaniards aged around 70 were divorced: up 3,000 from 2005. They want to enjoy their final years in the fullest sense. The old saying that it is never too late has never been truer.
Take the case of Encarna, who is 66, and only lost her virginity last year. The lucky man who took her maidenhead was 78-year-old Pedro, who met Encarna at the Valencia retirement home they both live in. "After a lifetime working in Madrid, I wanted to make a new start by the seaside," says Encarna.
The two hit it off, and the relationship blossomed. "It was all very natural, like meeting a friend, and it then developing into something else," she says, adding that she had never felt strong enough feelings for anybody to want to go to bed with them. She says they reserved a hotel room, got dressed up, had dinner, and then went up to their room. Pedro says he was afraid he wasn't going to be "up to the task," but was satisfied with his performance. Encarna says the earth didn't exactly move for her, "but it got better with practice."
For the moment, the two live in separate rooms in their retirement home, meeting once a week for a date in a hotel. Pedro says he wants to make an honest woman of Encarna, but she says that she doesn't want "the problems that marriage brings."
"Some people do not discover their sexuality until they reach old age: widows and widowers who meet somebody new that satisfies them. There are also people who are relieved to be free of the burden of sex when their partner passes away or they separate," says sexologist María Pérez Conchillo of the Espill Institute in Valencia. "We have to remember that at whatever age, sex is about choice, not obligation."