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The Journals of Gerontology Series B: Psychological Sciences and Social Sciences logoLink to The Journals of Gerontology Series B: Psychological Sciences and Social Sciences
. 2019 May 27;75(8):1772–1782. doi: 10.1093/geronb/gbz074

A National Longitudinal Study of Partnered Sex, Relationship Quality, and Mental Health Among Older Adults

Yan Zhang 1, Hui Liu 1,✉
Editor: Deborah Carr
PMCID: PMC7489086  PMID: 31132123

Abstract

Objectives

We worked from a life course perspective to examine the relationship between partnered sex and older adults’ trajectories of mental health as well as the potential mediating role of relationship quality in this association.

Method

We analyzed nationally representative data from three waves of the National Social Life, Health, and Aging Project (2005/2006 to 2015/2016). The sample included 1,911 married and cohabiting respondents aged 57 to 85 at the baseline survey. We examined four factors related to partnered sex: being sexually active, sexual frequency, feeling okay with sexual frequency, and sexual quality. Mental health was measured by self-rated poor mental health, unhappiness, and psychological distress. The relationship quality measures considered both relationship support and relationship strain.

Results

Results from mixed-effects models suggest that being sexually active, having sex more frequently, feeling okay with sexual frequency, and reporting better sexual quality were all related to better mental health outcomes. Relationship quality partially explained the effects of sex on mental health.

Discussion

This study highlights the importance of sex for mental health and relationship quality among older adults. The findings have implications for health policy and programs that seek to promote healthy aging.

Keywords: Depression, Life course analysis, Sexual behavior, Successful aging

Scientific studies have shown that involvement in social relationships promotes individuals’ health and well-being (Kawachi & Berman, 2001; Umberson & Montez, 2010). Yet, partnered sex (i.e., sex within a partnered relationship)—one of the fundamental dimensions of intimate relationships, is a relatively understudied area, especially in the aging population. We focus on partnered sex because for the current cohort of older adults, most sexual activities occur within an established partnered relationship (Galinsky, McClintock, & Waite, 2014; Liu, Waite, Shen, & Wang, 2016). So far, we know little about whether and how partnered sex shapes older adults’ mental health. According to a nationally representative survey about sexual attitudes and practices to adults ages 45 and older, a large proportion of older Americans believe that sex is critical to a good relationship and agree that sex is important to their overall quality of life (AARP, 2010). This result indicates that, at least in older individuals’ own assessments, partnered sex may promote psychological well-being and healthy aging.

Guided by a life course perspective, we examined the association between partnered sex and mental health among older adults. We analyzed three waves of longitudinal data from the National Social Life, Health, and Aging Project (NSHAP) to address five specific research questions: (a) Is being sexually active with a partner related to better mental health in late life? (b) Is higher frequency of sex related to better mental health? (c) Is feeling okay with the sexual frequency related to better mental health? (d) Is better sexual quality related to better mental health? and (e) Are the associations between sex and mental health explained by relationship quality? This study is particularly important given the continuous increase in life expectancy, which has likely expanded the number of years in which older adults can potentially engage in sexual activities (DeLamater, 2012). The importance of this study is further highlighted by growing scholarly and public recognition of the importance of sexual well-being for older adults (Laumann et al., 2006; Rosen & Bachmann, 2008). The findings also have significant implications for health policy and programs that seek to promote healthy aging.

Sex Lives and Mental Health: Limited Empirical Evidence

The global population is aging rapidly and approximately 20% of people over 55 suffer from mental health problems (U.S. Department of Health and Human Services, Administration on Aging, 2001). Relative to younger adults, older adults are more likely to experience multiple stressors simultaneously, such as reduced mobility, chronic pain, memory loss, and/or bereavement, all of which can trigger loneliness, depression, and unhappiness (Fried et al., 2015; Saczynski et al., 2010; Verhaak et al., 2005). Although the empirical knowledge about the risk factors for poor mental health is sound and growing, there has been little systematic investigation of how sex lives shape mental health among the aging population. The limited empirical evidence suggests that the incidence and frequency of sexual activity are related to certain dimensions of mental health. For example, using the first wave (2005–2006) of NSHAP, Ganong and Larson (2011) found that having sex in the past year was associated with lower levels of depression among older adults (ages 57–85). Further, a recent study of older adults in England (ages 57–75) examined inflammatory biomarkers and found that more frequent sex was related to a lower level of stress-related inflammation and thus better quality of life (Allen, 2017).

A growing body of research, primarily clinical-based studies, has examined the link between sexual activity and physical health, among midlife and older adults. These studies suggest that frequent sexual intercourse and orgasm are correlated with a lower risk of heart disease, breast cancer, and prostate cancer (Ebrahim et al., 2002; Giles et al., 2003; Petridou et al., 2000), although there is also evidence showing that a very high frequency of sex is related to higher CVD risk, especially among older men (Liu et al., 2016). Because physical health is strongly correlated with mental health (Ohrnberger, Fichera, & Sutton, 2017), especially for older adults (many of whom experience a chronic disease or side effects of medication), there is reason to expect that sexual activity is also related to mental health.

Prior studies on the link between sex and health have focused more on the quantitative aspects of sexual activity (e.g., being sexually active, frequency of sex) but less on sexual quality (Brody, 2010), defined as “subjective sexual well-being, perceived quality of an individual’s sexuality, sexual life, and sexual relationships” (Laumann et al., 2006, p. 146). Using data from the Global Study of Sexual Attitudes and Behaviors (a survey of 27,500 men and women age 40–80 living in 29 countries), Laumann et al. (2006) found that subjective sexual well-being (measured as physical and emotional satisfaction) was a strong predictor of overall happiness. Another study of women age 40–65 found that greater enjoyment of partnered sexual activity was associated with more social support, better emotional well-being, and a greater sense of purpose in life (Prairie et al., 2011). Nevertheless, sexual quality of older adults has received minimal research attention, especially the specific pathways through which it links to elderly well-being.

Partnered Sex, Relationship Quality and Mental Health Among Older Adults: A Life Course Perspective

A life course perspective locates people “in history through birth years” and “through the social meanings of age-graded events and activities” (Elder & O’Rand, 1995, p. 454). According to the life course theory, individuals’ sexual histories and sexual relationships may vary across social contexts over time, especially at different ages. Many studies on sex lives, however, have focused solely on younger or mid-age adults, who are usually considered to be in the most sexually active stages of life (DeLamater & Sill, 2005). The scientific understanding of partnered sex in later life is limited. Two common conceptions are that older adults do not have sex as often as their younger counterparts and that sexual quality tends to decline at older ages (DeLamater, 2012; Lindau et al., 2007). While the prevalence of sexual activity does decline with age, a substantial proportion of men and women continue to engage in sexual activity in their 60s, 70s, and beyond, mostly within partnered relationships (DeLamater, 2012). Based on data from a nationally representative sample, more than half of men and women between the ages of 57 and 74 in the United States continued to be sexually active (Laumann et al., 2006). Moreover, a sizable proportion of older people reported that sex is a key part of their relationship and well-being (DeLamater, 2012; Lindau et al., 2007).

Relationship quality—broadly defined as partners’ subjective appraisals of their relationships, including in terms of satisfaction, happiness, strain, and conflict—is an important factor that is related to both sex and subjective well-being over the life course (Carr, Cornman, & Freedman, 2016; Galinsky & Waite, 2014). Empirical studies have shown that higher frequency of sexual interaction with a partner was linked to better marital quality (Galinsky & Waite, 2014), improved relationship closeness (Basson, 2001) and reduced relationship strain within couples (Orr, Layte, & O’Leary, 2019); and sexual satisfaction was strongly associated with perceived relationship quality for both men and women (van den Brink et al., 2018). Moreover, family scholars have consistently emphasized the importance of relationship quality for both physical and mental health over the life course (Umberson & Montez, 2010; Waite, Luo, & Lewin, 2009). Many types of scientific evidence demonstrated that a good relationship quality promoted mental health while relationship conflict and strain were sources of stress and depression, which eroded mental health (Umberson & Montez, 2010; Leach et al., 2013). Therefore, we expect relationship quality to be a potential pathway linking partnered sex and mental health.

Taken together, we hypothesize the following patterns:

Hypothesis 1: Being sexually active is related to better mental health.

Hypothesis 2: Higher sexual frequency is related to better mental health.

Hypothesis 3: Feeling okay with sexual frequency is related to better mental health.

Hypothesis 3: Better sexual quality is related to better mental health.

Hypothesis 4: The association between sex and mental health is, at least partially, explained by relationship quality.

Method

Data and Sample

We used nationally representative longitudinal data from the three waves of the NSHAP. The NSHAP, one of the first national-scale, population-based studies of health and intimate relationships at older ages, was conducted by NORC at the University of Chicago. The first wave (2005/2006) surveyed a national probability sample of 3,005 community-dwelling men and women ages 57–85 in the United States (Waite et al., 2014). In the second wave (2010/2011), 3,377 respondents completed the survey, including 2,261 Wave 1 respondents who were re-interviewed. The Wave 3 (2015/2016) survey was completed by 4,777 respondents, including 2,350 respondents from Wave 2 and 2,250 new refreshment respondents (Waite et al., 2014; Waite et al., 2014; Waite, 2017).

To take advantage of the longitudinal data, we restricted the focal sample to the 3,005 respondents who were first interviewed at Wave 1. The newly added sample in Waves 2 and 3 was not included due to shorter duration of follow-up or no follow-up. Additional analysis (results shown in Supplementary Table S7) suggested that including the newly added respondents in Waves 2 and 3 showed similar findings as reported in the paper. We further restricted our sample to those who were married or cohabiting because we focused on partnered sex and because sexual activity at older ages is almost exclusively experienced within couples (Galinsky, McClintock, & Waite, 2014; Liu, Waite, Shen, & Wang, 2016). The final analytic sample included 1,911 respondents who contributed to 4,109 person-period observations across three waves. 26.48% of the respondents had missing values on sex variables, and 1.83% of the respondents had missing values on mental health and other key control covariates (Supplementary Table S2). We used the multiple imputation method to impute the missing data in Stata (StataCorp, 2017). Specifically, we used Multiple Imputation by Chained Equations (MICE) that is particularly useful for large imputation procedures (Azur, Stuart, Frangakis, & Leaf, 2011). Results from additional analyses (not shown but available upon request) suggested that using other methods to deal with the missing values such as listwise deletion or Heckman-type correction for sample selection bias (Heckman, 1979) revealed similar findings as we reported in the article.

Measures

Partnered sex

The NSHAP defines sex as “any mutually voluntary activity with another person that involves sexual contact, whether or not intercourse or orgasm occurs” (Lindau et al., 2007). In this study, we examined the following sex factors (all time-varying, measured across all waves) that are available in the data and also often considered as key aspects of sex lives (e.g., Liu et al., 2016):

  • 1) Being sexuality active. The survey asked whether the respondent had sex with their partner in the last year (1 = yes, 0 = no). Respondents who answered yes were defined as sexually active.

  • 2) Sexual frequency. Respondents were asked how often they had sex with their current partner or a recent partner during the last 12 months. Response categories included none (reference), once a month, two to three times a month, and once a week or more.

  • 3) Okay with sexual frequency. Respondents were asked whether they would say that they had sex “about as often as they would like” (reference), “less often than they would like” or “more often than they would like”.

  • 4) Sexual quality. Sexuality scholars distinguish two dimensions of sexual quality: physical pleasure and emotional satisfaction (Laumann et al., 2006; Waite & Joyner, 2001). Respondents were asked how physically pleasurable they found their sexual relationship and how emotionally satisfied they found their sexual relationship. Using the answers to these two questions, we created two measures, one for the physical dimension of sexual quality and one for the emotional dimension. Because both measures are left-skewed, we collapsed the lower-end categories and recoded the variables into three categories: not very pleasurable/satisfied (reference, including none, slightly, and moderately), very pleasurable/satisfied, and extremely pleasurable/satisfied.

Mental health

We analyzed three measures of mental health (all time-varying): self-rated poor mental health, unhappiness, and psychological distress. These measures reflect the most commonly studied mental health measures available in the data. The measure of self-rated poor mental health was recoded based on respondents’ ratings of their mental health as excellent (1), very good (2), good (3), fair (4), or poor (5). The unhappiness measure was recoded from respondents’ assessments of how happy their life was on the whole: extremely happy (1), very happy (2), pretty happy (3), unhappy sometimes (4), or unhappy usually (5). Finally, we used the 11-question subset of the Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977) to measure psychological distress. Respondents were asked how often in the past week they experienced any of the following: (a) I did not feel like eating; (b) I felt depressed; (c) I felt that everything I did was an effort; (d) My sleep was restless; (e) I was happy; (f) I felt lonely; (g) People were unfriendly; (h) I enjoyed life; (i) I felt sad; (j) I felt that people disliked me; and (k) I could not get going. For each of the 11 items, response categories ranged from 0 (rarely or none of the time) to 3 (most of the time). The final measure was the sum of the 11 scores with higher value indicating higher distress (alpha coefficient = 0.80).

Relationship quality

We followed previous studies (e.g., Galinsky & Waite, 2014; Liu & Waite, 2014; Warner & Kelley-Moore, 2012) to calculate relationship quality scales using the NSHAP data. We used six items that are available across all waves to construct time-varying relationship quality scales. First, respondents were asked how happy they were in their relationship (Item 1: 1 = very unhappy to 7 = very happy). Because Item 1 was highly skewed, we collapsed the values to: 1 = unhappy (1, 2, 3, 4), 2 = happy (5, 6), and 3 = very happy (7). Respondents were also asked the extent to which they preferred to spend their free time doing things with their partner (Item 2). Responses include (1) mostly together, (2) some together and some apart, and (3) mostly apart. We reverse-coded this item so that higher values indicate better relationship quality. Finally, respondents were asked: how often they could open up to the partner if they needed to talk about their worries (Item 3), how often they could rely on their partner for help if they had a problem (Item 4), how often their partner made too many demands on them (Item 5), and how often their partner criticized them (Item 6). Responses to each question (Items 3–6) are (1) never, hardly ever, or rarely, (2) some of the time, and (3) often. Results from iterated principle factor method and an oblique rotation suggest that these six items form two opposite dimensions, which we refer to as relationship support—reflecting the positive dimension of the relationship, and relationship strain—reflecting the negative dimensions of the relationship (Liu, Shen, & Nsieh, 2018). Table 1 shows the factor loadings of each item used to generate the factor scores for relationship quality without imputed data.

Table 1.

Relationship Quality Factor Loadings (N of person-period = 4,109, N of respondents = 1,911)

Relationship support Relationship strain
How happy is your relationship? 0.48 −0.18
How often can you open up to your partner? 0.67 0.03
Do you spend your free time together? 0.38 −0.04
How often can you rely on your partner? 0.64 0.03
How often does your partner criticize you? 0.04 0.81
How often does your partner make too many demands on you? −0.09 0.51
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Note. Bold numbers indicate factor loadings above the 0.35 cutoff point. Factor loadings are based on non-imputed items.

Covariates

We controlled basic socio-demographic covariates, all measured at Wave 1, including: age was measured as a continuous variable in years; race/ethnicity included four categories: non-Hispanic white (reference), non-Hispanic black, Hispanic, and other; education was grouped into four categories: less than high school (reference), high school degree or equivalent, some college, and college graduate. All covariates including gender are time-invariant except age. In addition, because physical health is related to both sex lives and mental health, we also controlled for self-rated poor physical health (0 = good/very good/excellent, 1 = poor/fair, time-varying). Moreover, sexual dysfunction is also related to sexual activity, sexual quality, and mental health. We combined two gender-specific sexual dysfunction variables into one measure for sexual dysfunction (time-varying): having trouble getting or maintaining an erection for men (1 = yes, 0 = no), and having trouble lubricating for women (1 = yes, 0 = no) (Liu, Shen, & Nsieh, 2018). We also controlled for whether men and women reported experiencing pain during sex (1 = yes, 0 = no, time-varying). Last, we controlled a flag for missing where the variable takes on the value of 1 for missing and 0 for non-missing.

Analytical Methods

We used multilevel mixed-effects models to handle the nested distribution of the longitudinal data. A major advantage of multilevel mixed-effects models (compared to traditional regression analysis) is the ability to distinguish the two types of heterogeneity (within- and between-individual) in estimates of the effects of the sex variables on changes in mental health. Mixed-effects models account for the unobserved heterogeneity related to the nested distribution of the longitudinal data by allowing random effects to vary across individuals. The linear mixed-effects model was specified as:

Level 1:Yij=π0i+π1iTij+ γ Sexij+ Zij′C+εij
Level 2:π0i=β00+Xi′A0+δ0i
π1i=β10+Xi′A1

where Yij is ith individual’s mental health outcome at time j. π0i is the initial mental health score for the ith individual at Wave 1 (random effect). π1i is the slope of the mental health trajectory for the ith individual across waves. For parsimony, we estimated π1i as a fixed effect rather than a random effect because the preliminary analysis suggested little variation in this parameter and adding a stochastic component for π1i didn’t improve the model. Sexij indicates the time-varying sex variables included in the model and γ is the corresponding coefficient—the focus of our interpretation. Xi is the vector of Wave 1 time-invariant covariates and Zij is the vector of time-varying covariates. εij is the level-1 residual (within-individuals) and δ0i is the level-2 residual (between-individuals). We used Stata 15 to estimate the models (StataCorp, 2017).

We estimated separate mixed-effects models for each mental health outcome. Because the sex variables may be correlated with one another, we also estimated separate models for each sex factor. We conducted three models for each combination of mental health outcome and sex variable (e.g., self-rated poor mental health and sexual frequency). For each combination, Model 1 analyzes the basic effects of sex on mental health controlling for all covariates. Model 2 adds an interaction term for sex and analytic time (i.e., survey year) to assess how mental health trajectories change over time in response to sex. Model 3 adds relationship support and relationship strain to test if they can explain the relationship between sex and mental health. To better understand relationship quality as a potential pathway, we further estimated the associations between sex and relationship quality using mixed-effects models. We have also tested an additional model by including gender interaction with sex, and the results (not reported but available upon request) showed few significant gender differences in the relationship between sex and mental health.

Results

Table 2 displays the descriptive statistics of all analyzed variables. In our sample, 57.17% of partnered older adults had sex last year, and about 16.72% had sex once a week or more. However, about 40% felt that the sexual frequency was less often than they wanted to have. 37.33% of the respondents felt very physically pleasurable, and 29.57% of them felt extremely physically pleasurable in sexual relationship. 39.79% of the respondents felt very emotionally satisfied, and 32.44% of the respondents felt extremely emotionally satisfied in sexual relationship.

Table 2.

Descriptive Statistics of all Analyzed Variables, N of Person-Period = 4,109, N of Respondents = 1,911, National Social Life, Health, and Aging Project (NSHAP) 2005/2006 to 2015/2016

Variables Mean (SD)/% Variables Mean (SD)/%
Mental health Covariates
 Self-rated poor mental health 2.21 (0.96)  Men 60.18
 Unhappiness 2.29 (0.84)  Age 67.80 (9.43)
 Psychological distress 4.69 (4.69)  Education
Sex variables   <High school (ref) 17.30
 Had sex last year   High school/Equivalency 24.14
 No (ref) 39.72   Some college 31.15
 Yes 57.17   College Graduate 27.40
 Sexual frequency  Race/ethnicity
 None (ref) 39.72   Non-Hispanic White (ref) 74.79
 Once a month 20.86   Non-Hispanic Black 11.56
 2–3 times a month 17.89   Hispanic 10.95
 Once a week or more 16.72   Other 2.36
 Ok with frequency  Self-rated physical health
 As often as wanted (ref) 37.92   Poor or fair (ref) 23.31
 Less often than wanted 39.99   Good/very good/excellent 76.59
 More often than wanted 3.89  Sexual dysfunction
Physical pleasure   No (ref) 44.44
 None/slightly/moderately (ref) 28.21   Yes 29.72
 Very 37.33  Experienced pain during sex
 Extremely 29.57   No (ref) 69.80
Emotional satisfying   Yes 5.69
 None/slightly/moderately (ref) 24.95 Relationship quality
 Very 39.79  Relationship support 0.07 (0.77)
 Extremely 32.44  Relationship strain −0.04 (0.87)
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Note. All variables are time-varying except gender, education and race/ethnicity.

Table 3 presents the results from the mixed-effects models that assess the effects of being sexually active, sexual frequency, okay with frequency, physical pleasure, and emotional satisfaction on the mental health outcomes, respectively (full tables with all covariates are reported in Supplementary Tables S3–S7). Results in Model 1 of Panel A suggest that, when all covariates are held constant, being sexually active was negatively related to self-rated poor mental health (b = −0.16, p < .001), unhappiness (b = −0.14, p < .001) and psychological distress (b = −0.61, p < .001). In addition, more frequent sex was also negatively related to poor mental health, unhappiness, and psychological distress (Model 1 in Panel B). For example, results from Model 1 in Panel B suggest that compared to those who had no sex last year, those who had sex once a week or more reported self-rated poor mental health by 0.25 unit lower (p < .001), unhappiness by 0.25 unit lower (p < .001), and psychological distress by 0.80 unit lower (p < .001); and those who had sex 2–3 times a month also reported significantly lower values in self-rated poor mental health (b = −0.19, p < .001), unhappiness (b = −0.18, p < .001), and psychological distress (b = −0.65, p < .01). Further, results in Model 1 of Panel C show that those who felt their sexual frequency was less often than they wanted reported poor mental health by 0.18 unit higher (p < .001), unhappiness by 0.19 unit higher (p < .001), and psychological distress by 0.95 unit higher (p < .001) than those who felt satisfied with their sexual frequency; and those who felt their sexual frequency was more often than they wanted also reported significantly higher levels of psychological distress (b = 0.76, p < .05) than those who felt satisfied with their sexual frequency, although they were not different from each other in terms of self-rated poor mental health and unhappiness. Finally, results in Model 1 of Panel D and E indicate that those who felt very or extremely physically pleasurable and those who felt very or extremely emotionally satisfied in their sexual relationships both reported significantly lower levels of self-rated poor mental health, unhappiness, and psychological distress than those who did not feel so in their sexual relationships.

Table 3.

Estimated Regression Coefficients From Mixed-Effects Models Predicting Mental Health Using Sex Variables, National Social Life, Health, and Aging Project (NSHAP) 2005/2006 to 2015/2016 (N of Person-Period = 4,109, N of Respondents = 1,911)

Self-rated poor mental health Unhappiness Psychological distress
(1) (2) (3) (1) (2) (3) (1) (2) (3)
Panel A: Had sex last year (ref: no) −0.16*** −0.23*** −0.19*** −0.14*** −0.19*** −0.13** −0.61*** −0.24 0.02
Year −0.01** −0.02** −0.02*** 0.01* 0.00 0.00 −0.02 0.02 0.02
Sex*Year 0.01* 0.02* 0.01 0.01* −0.07* −0.06
Relationship support −0.14*** −0.25*** −0.89***
Relationship strain 0.06** 0.09*** 0.61***
Panel B: Sexual frequency (ref: no)
 Once a month −0.10* −0.17** −0.15* −0.05 −0.09 −0.06 −0.36 −0.03 0.11
 2–3 times a month −0.19*** −0.23*** −0.18** −0.18*** −0.26*** −0.19** −0.65** −0.12 0.20
 Once a week or more −0.25*** −0.32*** −0.26*** −0.25*** −0.25*** −0.17** −0.80*** −0.20 0.15
Year −0.01* −0.02** −0.02** 0.01* 0.00 0.00 −0.01 0.04 0.04
Once a month*Year 0.01 0.02 0.01 0.01 −0.05 −0.03
2–3 times a month*Year 0.01 0.01 0.02* 0.02** −0.10* −0.09
Once a week or more*Year 0.02 0.02 −0.00 −0.00 −0.14** −0.12*
Relationship support −0.14*** −0.25*** −0.89***
Relationship strain 0.06*** 0.09*** 0.60***
Panel C: Okay with frequency (ref: as often as wanted)
 Less often than wanted 0.18*** 0.20*** 0.16*** 0.19*** 0.23*** 0.18*** 0.95*** 1.10*** 0.86***
 More often than wanted 0.10 0.17* 0.15 0.06 0.03 −0.01 0.76* 1.14* 0.98*
Year −0.01* −0.01 −0.00 0.01 0.01* 0.01* −0.03 −0.00 0.00
Less often*Year −0.01 −0.01 −0.01 −0.01 −0.04 −0.04
More often*Year −0.02 −0.02 0.01 0.01 −0.10 −0.10
Relationship support −0.13*** −0.24*** −0.85***
Relationship strain 0.06*** 0.10*** 0.62***
Panel D: Physical pleasure (ref: not very pleasurable)
 Very pleasurable −0.21*** −0.15** −0.09 −0.31*** −0.26*** −0.16*** −0.81*** −0.96*** −0.51*
 Extremely pleasurable −0.39*** −0.40*** −0.31*** −0.58*** −0.56*** −0.41*** −1.22*** −1.38*** −0.68**
Year −0.01* −0.00 −0.00 0.01 0.01* 0.01* −0.02 −0.04 −0.04
Very pleasurable*year −0.02* −0.02* −0.01 −0.01 0.04 0.04
Extremely pleasurable*year 0.01 0.01 −0.00 −0.00 0.04 0.04
Relationship support −0.10*** −0.19*** −0.82***
Relationship strain 0.06** 0.08*** 0.60***
Panel E: Emotional satisfaction (ref: not very satisfied)
 Very satisfied −0.22*** −0.19*** −0.11* −0.33*** −0.27*** −0.13** −1.15*** −0.93*** −0.22
 Extremely satisfied −0.40*** −0.43*** −0.32*** −0.65*** −0.59*** −0.40*** −1.33*** −1.28*** −0.28
Year −0.01* −0.01 −0.01 0.01* 0.02*** 0.02*** −0.01 0.01 0.02
Very satisfying*Year −0.01 −0.01 −0.02* −0.02* −0.05 −0.05
Extremely satisfying*Year 0.01 0.01 −0.01* −0.01* −0.01 −0.01
Relationship support −0.09*** −0.18*** −0.83***
Relationship strain 0.05** 0.07*** 0.61***
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Notes. In all models, we controlled gender, age, race/ethnicity, education, self-rated physical health, sexual dysfunction variables, survey year, and missing flag. Within-individual and between-individual variances are omitted, but they are all significant.

*p < .05, **p < .01, ***p < .001.

To understand how mental health trajectories change over time in relation to sex, we added interactions between sex variables and survey year in Model 2 of Table 3. Based on these results, we graphically presented significant interaction results (p < .05) in Figure 1. Generally, Figure 1 shows some mixed patterns. The self-rated mental health gap between those who were sexually active and those who were sexually inactive decreased over time due to a more rapid decline in poor mental health among the sexually inactive group than the sexually active group (Figure 1A). We also see a narrowing gap in unhappiness by sexual frequency, driven by a more rapid increase in unhappiness among those who had sex two to three times a month than those who had no sex last year (Figure 1C). In contrast, there were widening gaps in psychological distress between those who were sexually active and those who were sexually inactive (Figure 1B), as well as across sexual frequency groups (Figure 1D). Moreover, both the self-rated mental health gap by physical pleasure (Figure 1E) and the unhappiness gap by emotional satisfaction slightly increased over time.

Figure 1.

Figure 1.

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(A) Predicted scores of self-rated poor mental health and sexual activity interacting with survey year; (B) Predicted scores of psychological distress and sexual activity interacting with survey year; (C) Predicted scores of unhappiness and sexual frequency interacting with survey year; (D) Predicted scores of psychological distress and sexual frequency interacting with survey year; (E) Predicted scores of self-rated poor mental health and physical pleasure interacting with survey year; (F) Predicted scores of unhappiness and emotional satisfaction interacting with survey year. Predicted scores are calculated based on results from Model 2 of Table 3. Only statistically significant effects are shown in figures (p < .05).

To better understand the role of relationship quality, we added relationship strain and support in Model 3 of Table 3 and further used sex variables to predict relationship quality in Table 4. Results in Model 3 of each Panel suggest that, first, relationship support was negatively related to, and relationship strain was positively related to poor mental health, unhappiness, and psychological distress. Second, a majority of the main effects of sex variables decreased from Model 2 to Model 3 after adding relationship support and strain although they still remained significant. Some of the associations (e.g., emotional satisfaction and psychological distress) in Model 2 were no longer statistically significant in Model 3, suggesting that relationship quality explained the associations. Third, some interaction effects of sex by survey year became insignificant after the relationship quality variables were added. In particular, a majority of the widening gaps in psychological distress by sexual activities (Figure 1B and D) became insignificant after we added relationship quality variables, although relationship quality did not explain the widening mental health gaps by sexual quality (Figure 1E and F) or the narrowing gaps by sexual activities (Figures 1A and C). Results in Table 4 further suggest that being sexually active, higher sexual frequency, and better sexual quality were all positively related to relationship support, and negatively related to relationship strain (Model A, B, D, and E). Additionally, compared with respondents who felt satisfied with their sexual frequency, those who felt they had sex less often than they wanted reported lower relationship support and higher relationship strain, and those who felt they had sex more often than they wanted reported lower relationship support.

Table 4.

Sex Variables and Relationship Quality, N of Person-Period = 4,109, N of Respondents = 1,911, National Social Life, Health, and Aging Project (NSHAP) 2005/2006 to 2015/2016

Variables Relationship support Relationship strain
Model A: Had sex last year (ref:no) 0.21*** −0.21***
Model B: Sexual frequency (ref: no)
 Once a month 0.15*** −0.16***
 2–3 times a month 0.26*** −0.25***
 Once a week or more 0.28*** −0.29***
Model C: Okay with frequency (ref: as often as wanted)
 Less often than wanted −0.16*** 0.16***
 More often than wanted −0.15* 0.10
Model D: Physical pleasure (ref: not very pleasurable)
 Very pleasurable 0.40*** −0.24***
 Extremely pleasurable 0.59*** −0.40***
Model E: Emotional satisfaction (ref: not very satisfying)
 Very satisfying 0.62*** −0.38***
 Extremely satisfying 0.82*** −0.57***
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Notes. In all models, we controlled gender, age, race/ethnicity, education, self-rated physical health, sexual dysfunction variables, survey year, and missing flag. Within-individual and between-individual variances are omitted, but they are all significant.

*p < .05, **p < .01, ***p < .001.

Discussion

Today, older adults are living longer than ever before, and thus have potentially extended sexual lives (DeLamater, 2012). Yet, sex in late life remains understudied, and its consequence on health and well-being in late life is less clear. This study, based on a nationally representative longitudinal dataset, is one of the first empirical studies linking partnered sex to mental health among older adults from a life course perspective. Results highlight the importance of both the quantity and quality of sex for older adults’ mental health. Consistent with our hypotheses, we found that being sexually active (H1), having sex more frequently (H2), feeling okay with sexual frequency (H3), and having better sexual quality (H4) were all related to better mental health among older adults. Moreover, relationship quality partially explained the effects of sex on mental health (H5).

In order to fully understand what aspects of sex relate to mental health, we considered both quantitative and qualitative dimensions of sex lives. Quantitatively, both being sexually active and more frequent sex were associated with better mental health. This is consistent with some clinical evidence that assessed the relationship between sexual activity and mental health from an endogenic perspective (Carter, 1998; Dfarhud, Malmir, & Khanahmadi, 2014). For example, sexual activities promote a feeling of love, relaxation and social attachment that help individuals release dopamine, endorphins or oxytocin and in turn reduce individuals’ anxiety and stress (Carter, 1998; Dfarhud, Malmir, & Khanahmadi, 2014). For older adults who have experienced declined sexual activities in later life, subjective assessment of sexual activity is also an important determinant of good mental health. We found that feeling sexual frequency both less or more often than wanted was strongly associated with poor relationship quality and poor mental health outcomes, indicating a negative effect on mental health through unfulfilled sexual desire or overburdened by partner’s sexual desire. This finding is consistent with some previous evidence suggesting that mismatch or disagreement about sex within couples is harmful to relationship quality and subjective well-being (Orr et al., 2019; Little, McNulty, & Russell, 2010). In terms of sexual quality, our findings resonate previous studies on subjective sexual well-being, showing that both physical pleasure and emotional satisfaction in sexual relationship were related to overall happiness (Laumann, 2006). Our findings are also consistent with previous literatures suggesting that good sexual quality was related to better health and well-being (Liu & Waite, 2014; Liu et al., 2016; Prairie et al., 2011).

Our results further suggest that the benefits of sex on mental health may work through the path of promoting relationship quality within couples. This is because high frequent sex and good quality of sex in a relationship are important factors responsible for couples’ senses of love, belonging, intimacy, and emotional support (Blieszner, 2006; Carter, 1998), and these positive outcomes within relationship increase individuals’ quality of life and reduce psychological distress (Umberson & Montez, 2010). Feeling satisfied with their sexual frequency also benefits relationship quality, and then promotes couples’ mental health. This may reflect that couples who have harmonious synchronicity in sexual desire tend to have good communication with partner towards the importance of sex, which is highly correlated with good relationship quality and life quality (Gillespie, 2017). Overall, our findings support the hypothesis that relationship quality is a mechanism linking sex and mental health. Older adults who have frequent sex and good quality of sex are more likely to gain support from partners and less likely to have relationship strain, which all benefit their mental health.

Moreover, we found that the associations between partnered sex and mental health tended to change over time, although the directions of the changes may depend on the quantity or quality of sex as well as the specific measures of mental health. For sexual quality, there were some evidence for widening gaps in self-rated poor mental health and unhappiness by sexual quality, indicating that sexual quality might become even more important for mental health as one ages. This is consistent with theories of cumulative advantage/disadvantages from a life course perspective (Dannefer, 2003). For quantitative aspects of partnered sex (i.e., being sexually active, sexual frequency), the evidence is mixed depending on the specific mental health outcomes. We found that the effects of being sexually active and sexual frequency on psychological distress tended to increase over time, and this widening gap was partially explained by relationship quality. Having sex and having more frequent sex are related to better relationship quality, which may reduce psychological distress. However, there is some evidence showing narrowing gaps in poor mental health between the sexually active and inactive groups as well as in unhappiness between having no sex and having sex two to three times a month groups. This is consistent with the self-assessed results in AARP (2010) that both men and women reported the importance of having sex to quality of life tended to decrease, compared to their experience 10 years ago (AARP, 1999). It is possible that decreased frequency of sex in later waves is accompanied by increased functional limitations as people age, which may reduce the benefits of sex. Nevertheless, sexual involvement, particularly being sexually active, higher frequency of sex and better quality sex, was related to better mental health throughout the entire study period, during which some respondents reached their late 90s.

This study has several limitations. First, because the analysis was based on only three waves of data, we cannot fully determine the causal direction. It is likely that the causal relationship operates in the opposite direction: Older adults who have better mental health may engage in more frequent sex or experience greater sexual enjoyment than those who are in poor mental health suggesting a potential selection process. Indeed, previous empirical studies have shown that anxiety and depression are related to sexual dysfunction problems (Brody, 2010; Laumann et al., 2008; Moreira et al., 2008), which can reduce both involvements in sexual activities and sexual enjoyment. Further research using data from additional follow-up waves is needed to help identify the direction of causality and the longer-term trajectories of these relationships. Second, a gendered perspective is needed to examine how sex influences mental health. Although we tested gender interaction terms, we did not find significant and consistent gender differences between older men and older women. Future studies should explore more on gender differences in the link between sex lives and mental health as well as explore broader relationship compositions.

Despite its limitations, the current study makes significant contributions to the literature on sex in later life, especially research on the link between sex and mental health. Using nationally representative longitudinal data, we found that having sex, especially having more frequent sex, feeling okay with sexual frequency, and having better quality sex, were related to better mental health through promoting relationship quality among older adults. The findings highlight the importance of older people’s sex lives and well-being and speak to policy makers as the life expectancy of Americans increases and the aging population grows. Healthcare providers should discuss sexual activity with their older patients in order to preserve psychological vibrancy in later life. Given the limited research on the social and psychological aspects of sex among older adults, this study calls for more research efforts in this direction.

Funding

This research was supported by the National Institute on Aging K01 Award K01AG043417 to H. Liu.

Author Contributions

Y. Zhang planned the study, performed the data analysis, and wrote the article. H. Liu supervised the data analysis and contributed to revising the paper.

Conflict of Interest

None reported.

Supplementary Material

gbz074_suppl_Supplementary_Tables
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Supplementary Materials

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