SMF 212, Navigating Sexuality and Relationships in Mid/Later Life, is offered through the Department of Sexuality, Marriage and Family Studies at St. Jerome’s University within the University of Waterloo. The course was taught in Spring 2021 as a fully remote offering by Stacey Jacobs, a community sexual health educator with over twenty years of experience who has taught in the SMF program for a decade. The course examines how people navigate sexuality, intimacy, and relationships as they age, drawing on a biopsychosocial framework and attending to the ways in which age intersects with gender, sexual orientation, health, disability, culture, race, and socioeconomic status.

Jacobs approaches all course content from a sex-positive standpoint — a framework that affirms each person’s right to define and experience their sexuality across the lifespan, that avoids moralistic value judgments, and that celebrates the diversity of bodies, identities, and consensual practices.

Sources and References

Primary sources — De Lamater & Koepsel (2015), Sexual and Relationship Therapy; Fabbre (2015), The Gerontologist; Bartlett (2010), Liverpool Law Review; Holdsworth & McCabe (2018), Clinical Gerontologist

Online resources — Senior Planet (seniorplanet.org); Aging Life Care Association; Canadian Living; The Atlantic; Educational Gerontology

Chapter 1: Introduction — Language, Ageism, and the Aging Landscape

The Classroom Environment and Self-Care

Jacobs opens the course by acknowledging that sexuality and sexual health material can provoke a wide range of responses — happiness, relief, excitement, embarrassment, sadness, anger, stress, or anxiety — and invites students to make an autonomous, informed decision about enrolling. She distinguishes between intellectual discomfort, which is a normal and productive part of university learning (arising when our ideas are challenged and we must resolve cognitive dissonance — the psychological stress that occurs when a person holds contradictory beliefs and then acts against one of them), and being triggered, which refers to emotional trauma and is qualitatively different.

Two interrelated concepts frame the course ethos. Self-care refers to what individuals do to establish and maintain their physical, emotional, and mental health and to prevent burnout; examples range from sleeping in and cooking a favourite meal to taking a walk in nature or turning off one’s phone for an evening. Jacobs notes, however, that self-care has been heavily monetized and that participation in it does not require spending money. Community care, by contrast, involves using one’s privilege or initiative to support others — showing up for people without being asked, demonstrating compassion, and engaging in activism. These two forms of care are not mutually exclusive; research suggests that helping others also increases our own happiness. Taken together, they reflect a recognition that we are fundamentally social and interdependent beings.

Sex Positivity and Critical Thinking

The course takes a sex-positive approach, grounded in comprehensive sexuality education. The SERC definition used in lecture describes sex positivity as “an important ideology that acknowledges and affirms each person’s right to experience and define their sexuality throughout their lifetime in whatever way they choose… inclusive and respectful of a wide range of sexual experiences, expressions, consensual activities (including non-activity) and identities (including asexuality).” Importantly, sex positivity is not sex promotion; it is a non-judgmental stance that promotes comfort with one’s own sexuality and body, and that of others, while respecting personal choices.

Critical thinking is also foregrounded as a fundamental skill. We are constantly flooded with information about sex from traditional media, social media, music, and peers, and this information is often contradictory, filled with half-truths, or misleading. The core of critical thinking is skepticism — not taking things for granted — combined with maintaining an open mind. This applies especially to claims made by authority figures, celebrities, government sources, or the internet.

Language, Inclusive Communication, and Ableism

Language carries power and the potential to cause harm. The course emphasizes the importance of using inclusive, non-assumptive language. Rather than defaulting to “Hello guys,” one might say “Hello everyone, friends, or folks.” Rather than assuming a partner’s gender (“Do you have a girlfriend?”), one asks “Do you have a partner?” Rather than universalizing behaviour (“Everyone masturbates!”), one acknowledges variation (“Some people masturbate, some don’t, either is okay”). Practical examples of inclusive language include using “person with a vagina” or “person who menstruates” rather than gendered anatomical shorthand, and using “they” when someone’s pronouns are unknown. Person-first language — “person with a disability” rather than “disabled person” — is another application.

Ableist language refers to words or phrases that intentionally or inadvertently target a person with a physical or mental disability. Terms such as “crazy,” “lame,” “dumb,” “insane,” “psycho,” or “spaz” function as filler language with no meaningful content but with real potential to harm. The course asks students to reflect on the casual use of diagnostic categories (e.g., “I am so OCD”) as a form of ableism that trivializes genuine clinical conditions.

Age Terminology and Ageism

One of the first substantive topics is the language used to refer to older people. Terms in common use include older adult, elders, aging adult, senior, senior citizen, mature, old, and elderly. The Journal of the American Geriatrics Society (JAGS) issued a policy in 2017 requiring authors to use “older adult” when describing individuals aged 65 and older, and to provide specific age ranges when discussing research findings or clinical recommendations. This policy shift reflects a broader awareness of how language shapes attitudes.

Ageism is defined by the Ontario Human Rights Commission as a socially constructed way of thinking about older persons based on negative attitudes and stereotypes about aging, combined with a tendency to structure society on the assumption that everyone is young. Manifestations of ageism include media and marketing industries that sell products to stop or slow the aging process, the use of “old” as an insult, and the cultural privilege attached to appearing or being young. The course invites students to examine their own internalized assumptions about aging.

Defining midlife and later life is itself contested. Chronological age (the number of years lived) is only one lens; other factors that shape the lived experience of age include societal and cultural norms, gender, health and activity level, appearance, family composition, living situation, and the subjective sense of how old one feels. In the course, midlife is loosely defined as approximately ages 45–65 and later life as 65 and older, though this division is recognized as imprecise and socially constructed.

Life Expectancy and Active Aging

Life expectancy in Canada was approximately 82.52 years on average as of 2020, with projected figures of 79 years for men and 83 years for women (2017 data). Significant disparities exist among Indigenous populations: Inuit life expectancy was approximately 64 years for men and 73 years for women, while Métis and First Nations populations showed figures of 73–74 years for men and 78–80 years for women. These disparities reflect the structural inequalities created by colonialism and systemic racism.

Active life expectancy refers to the average number of remaining years lived in an independent state, free from significant disability. This figure is increasing for Canadians. Related to it is the concept of sexually active life expectancy — the average number of remaining years spent as sexually active — a concept that underscores the continued relevance of sexual health across the lifespan.

Historical and Social Context

To understand the sexuality of today’s older adults, it is essential to understand the historical and technological landscape in which they came of age. People born before 1970 did not grow up with the internet, smartphones, social media, computers, online dating, or online pornography. Their sexual socialization occurred in a world shaped by different norms and information environments.

The legal landscape governing sexuality also shifted dramatically during their lifetimes. In Canada: birth control became legal in 1969; same-sex sexual activity was decriminalized in 1969; abortion became legal in 1988; same-sex marriage was legalized in 2005. Ontario’s Health and Physical Education curriculum began recommending (though not requiring) sexual health education in 1966–1978, introduced a first mandatory curriculum in 1978, and only added a mandatory AIDS component in 1987 in direct response to the HIV/AIDS crisis. This means that many current older adults received little to no formal sexual health education.

Gender Roles, Social Scripts, and Intersectionality

Gender roles are the expected behaviours for people of various genders; they vary across cultures and historical periods and are socially constructed rather than biologically fixed. Social scripts are the series of behaviours, actions, and consequences expected in a given situation or environment. Sexual scripts are a subset of social scripts — guidelines for what sexual behaviour and encounters are supposed to look like. Social norms are the informal understandings that govern people’s behaviour. Together, these constructs explain why people often experience sex and aging through a lens of expectation and rule-following rather than personal authenticity.

Intersectionality, a concept coined by legal scholar Kimberlé Crenshaw in 1989 and now widely used in social sciences, captures how racism, sexism, ableism, and other forms of discrimination overlap and create unique, compounded burdens for people. It is not simply about having multiple identities; rather, it is about how social structures make those identities the source and vehicle of vulnerability. When institutional and social protections fail to address the complexity of overlapping oppressions — what Crenshaw calls “intersection failure” — people fall through the gaps of advocacy and support systems. In the context of this course, intersectionality is critical for understanding how the sexual health needs of older adults are shaped not just by age, but by gender, race, class, sexual orientation, disability, and a host of other intersecting factors.

The Gender Unicorn and the Genderbread Person are visual models used in the course to illustrate the difference between biological sex, gender identity, gender expression, and sexual/romantic attraction — and to convey that each of these dimensions exists on a spectrum rather than as a binary.

Chapter 2: Sexuality in Later Life — A Biopsychosocial Perspective

Framing Assumptions

This chapter begins by surfacing the assumptions that students and society at large hold about older adults and sex. The dominant cultural narrative treats older adults as asexual, frail, or past the age of sexual interest — assumptions that are not only inaccurate but actively harmful. When internalized, these stereotypes can prevent older adults from seeking sexual healthcare, disclosing their sexual activity to providers, or understanding their own sexuality as valid and worthy of attention.

The Biopsychosocial Perspective

The primary theoretical framework for understanding sexuality in later life is the biopsychosocial perspective, which integrates biological factors (health, illness, physiological changes), psychological influences (knowledge, attitudes, emotional well-being), and relational factors (quality and satisfaction of partnerships). This stands in contrast to a purely medical perspective, which focuses narrowly on physical and mental health, the effects of illness or treatment on sexual function, and dysfunction.

Research synthesized in the lecture reveals several key findings:

• Sexual activity remains important in later life; having a sexual partner and being in good health are major contributing factors.
• Normal physical changes of aging do not necessarily affect sexual functioning, but the meaning attached to those changes often does. Some people in later life come to see themselves as no longer sexually attractive even when their physical capacity is unchanged.
• For people with vaginas, the inability to reproduce following menopause can produce the mistaken belief that there is no longer a reason to engage in sexual activity.
• Medical illness is not a major factor in declining sexual desire or behaviour; stress (contributing to anxiety and depression) is identified as a more primary cause.
• A positive relationship between mental health and sexual functioning is well established.
• Many older adults take multiple medications — for blood pressure, cholesterol, pain, blood thinning, and sleep — that are known to affect sexual functioning. However, the research suggests that diagnosed illness and medication use are generally not correlated with frequency of sexual activity.
• Sexual desire may decrease with age in some studies, but access to a partner and overall health status are significant moderating variables.
• As people age, erectile difficulties and decreased vaginal lubrication become more common. Some people adapt by engaging in sexual activity that does not involve penile penetration; others may stop all sexual activity.
• Among people who sought treatment for sexually related concerns, the outcome was not an increase in sexual frequency but rather an increase in sexual satisfaction — an important distinction.

HIV and Older Adults

The lecture draws specific attention to HIV and aging. The National HIV/AIDS Strategy for the United States reports a continual rise in the number of individuals aged 50 and over contracting HIV each year. Several factors account for rising HIV rates among older adults:

1. People are living longer and remaining sexually active longer.
2. Medications such as Viagra have enabled continued penetrative sex for people who might otherwise have curtailed it.
3. Retirement communities provide greater opportunity for meeting and engaging with new sexual partners.
4. Older generations did not receive comprehensive sexual health education; the first reports of HIV did not emerge until 1981, when many of today’s older adults had already completed their formative sexual socialization.

Rates of condom use decline with age, and healthcare professionals are less likely to ask older adults about their sexual activity, which means HIV diagnosis in this population is frequently delayed. Delayed diagnosis delays treatment and education, worsening outcomes for individuals and increasing transmission risk in the community.

Diversity in Sexuality and Aging: The ADDRESSING Framework

To provide appropriate and adequate care, healthcare providers must understand how diversity shapes the attitudes, experiences, and sexual health needs of older adults. The ADDRESSING framework — a mnemonic covering Age and cohort effects, Degree of physical ability, Degree of cognitive ability, Religion, Ethnicity and race, Socioeconomic status, Sexual orientation, Individualistic life experiences, National origin, and Gender — provides a structured way to recognize the cultural factors and personal attributes that influence sexuality across the lifespan.

The lecture emphasizes that ageism reinforces the stereotype that older adults are not sexually active, and that healthcare providers internalize these stereotypes and consequently do not inquire about the sexual health of their older patients. This creates a cycle in which older adults’ sexual health concerns go unaddressed, which in turn reinforces the assumption that no such concerns exist.

Relationship Status, Widowhood, and the Gender Gap

A number of relational patterns are specific to later life. Many older women find themselves widowed because they tend to marry partners older than themselves and because women have a higher average life expectancy than men. The frequency of sexual activity among older adults is lowest for widows, highest for those who are married, and moderate for those who are divorced or never married. Marital satisfaction is positively correlated with frequency of sexual activity.

LGBTQ+ Older Adults

Older lesbian, gay, bisexual, transgender, and queer (LGBTQ+) adults have often navigated a lifetime of victimization — including violence, discrimination, and homophobia — that may prevent them from disclosing information about their sexuality to healthcare providers. There is less opportunity for many LGBTQ+ older adults to find partners, leading to greater isolation and less sexual activity than they might desire. Some individuals may suppress their sexual identity as they age, effectively re-entering the closet in institutional settings for reasons of safety. The lecture notes that existing research on aging and sexuality has largely focused on white, heterosexual, middle-class people — a significant limitation that must be acknowledged. Regardless of sexual identity, the research concludes: “older adults are in need of an accepting community that allows them to express their sexuality, and engage in healthy sexual activity.”

Discrimination and Its Health Consequences

A critical lens on structural oppression runs through the entire course. Racism, sexism, ageism, ableism, classism, heterosexism, ethnocentrism, sizeism, fatphobia, Islamophobia, homophobia, and transphobia all negatively affect physical, mental, and emotional health. They cause both acute and chronic stress; they prevent people from accessing the healthcare they deserve; and they shape every dimension of a person’s sexual health and relational well-being. Students are encouraged to hold these realities in mind throughout the course.

Chapter 3: Sexual Expression and Leisure in Later Life

Challenging Core Assumptions

This chapter engages most directly with the content of sexual activity in later life, and it does so by first dismantling a series of harmful assumptions. Drawing on the Canadian Research Network for Care in the Community’s Keep on Rockin: Sexuality and Aging resource, the course identifies four common myths: that older adults are not interested in discussing their sexuality with care providers; that older adults are too fragile to engage in sexual activity; that sex education need only focus on young people; and that sexuality is reducible to penile–vaginal penetration.

In response, the course offers a broad, inclusive definition of sexual activity: “Kissing, cuddling, hugging, holding, squeezing, touching, stroking, licking, biting, oral sex, vaginal sex, anal sex, digital sex, massaging, caressing, using toys, kink, masturbation, mutual masturbation, sexting, phone sex, rubbing naked bodies, rubbing clothed bodies…” This expansive conception resists the cultural equation of sex with penetrative intercourse and makes space for the many forms of sexual expression available to people of all ages and abilities.

Masturbation and Solo Sex in Later Life

Despite the documented health benefits of sexual activity, masturbation remains heavily stigmatized. As sex and relationship therapist Dr. David Pittle notes, “probably no other common activity carries such a burden of shame and guilt as masturbation.” The course asks students to sit with the inconsistency of a sexual health culture that encourages young people to delay sex with others while simultaneously not promoting masturbation as a healthy alternative.

For older adults specifically, the less frequently a person experiences arousal and orgasm, the harder both become to achieve — a use-it-or-lose-it principle with physiological grounding. Blood flow to the genitals is beneficial even in the absence of orgasm. Solo sex may require advance planning for older adults, including attending to comfort, privacy, and physical accessibility.

Prevalence data for masturbation among older adults are difficult to obtain due to survey non-response and social desirability effects, but studies consistently find that a substantial proportion of older men and women continue to masturbate into their seventies, eighties, and beyond. Barriers cited by older adults include shame rooted in early religious or moral upbringing, physical limitations such as arthritis or mobility restrictions, lack of privacy in assisted living or communal settings, and the false belief that solo sex is a substitute only appropriate in the absence of a partner.

The health benefits of solo sexual activity in later life are well-documented. They include: maintenance of genital tissue health through increased blood flow; reduction of cortisol and stress hormones; improved sleep quality; relief from chronic pain through endorphin release; and maintenance of pelvic floor muscle tone, which can help manage urinary incontinence.

Sex as Leisure: A Conceptual Reframing

A significant conceptual reframing comes from the academic field of leisure studies. Drawing on Berdychevsky and Nimrod’s (2017) netnographic study of online sexuality discussion forums, the lecture argues that sexual activity in later life — whether partnered or solo, with or without penetration — can usefully be understood as leisure: freely chosen activity performed for its own sake, with anticipated satisfaction. This reframing is significant because it moves sexuality out of the domain of reproduction and relational obligation and locates it in the domain of personal enjoyment, self-expression, and well-being.

Understood as leisure, sex in later life may enhance self-perception, a sense of well-being, and feelings of vitality. Regular sexual activity is associated with high self-esteem, a sense of competence, pleasure, intimacy, and an overall sense of happiness. It offers particular practical advantages for older adults: it is familiar, relatively safe, performed indoors, free, and can require minimal physical effort.

Leisure in general has a significant positive impact on older adults’ physical, psychological, social, and spiritual well-being, and can help people successfully navigate major life transitions such as retirement or the loss of a partner. However, constraints to leisure — including isolation, age-related norms, health challenges, low motivation, limited income, mobility restrictions, ageism, racism, sexism, homophobia, and transphobia — increase in number and impact as people age.

The specific barriers to sexual leisure in later life include questions of social acceptability (which depends on age, gender, and relationship status); the degree of sexual permissiveness in the historical period when the individual was coming of age; and internalized ageism — the process by which older adults incorporate social norms that devalue or marginalize older people, thereby policing their own sexuality.

The netnographic method employed by Berdychevsky and Nimrod involved observing technologically mediated communication in online networks without direct researcher intervention. The study found that many community members were interested in sex-related discussions but few participated — a phenomenon the researchers called “lurking.” Masturbation was rarely discussed, reflecting its continued status as taboo even in relatively open online communities.

Media Portrayals and Ageist Humor

Gatling and colleagues (2017) examined comedy films featuring older adults in sexual scenarios, analyzing how humor functions as a cultural mechanism for simultaneously acknowledging and dismissing senior sexuality. Films in this genre often generate laughter precisely through the juxtaposition of sexual desire with an aging body — the implicit joke being that old people wanting sex is itself absurd. The typical audience response — “You’ve got to be joking!” — reveals how deeply the asexual elder is entrenched as a cultural default.

This comedic treatment functions as a form of ageist denial. By laughing at senior sexuality, audiences avoid confronting their own anxieties about aging and desire. The course asks students to consider how this cultural pattern shapes older adults’ own self-perception: when the predominant cultural message is that your desires are a punchline, it becomes harder to hold them as valid.

The course also raises the question: Is pornography ageist? Most mainstream pornographic media features young, surgically augmented bodies, with cosmetic procedures being performed on vulvas specifically to make them appear younger. This reflects and reinforces cultural devaluation of older bodies as sexual. The small but growing genre of explicitly age-positive erotic content represents a counter-cultural response.

Sexuality During the COVID-19 Pandemic

The COVID-19 pandemic created conditions of prolonged isolation that had acute effects on the sexuality and intimacy of older adults. Social distancing measures disproportionately affected older people, who were categorized as a high-risk population and often found themselves confined to their homes or to long-term care facilities with visitors prohibited.

For partnered older adults living together, the pandemic produced extended periods of togetherness that some couples found renewing and others found stressful. For those living separately from partners — including many who had chosen Living Apart Together (LAT) arrangements — physical intimacy was interrupted for months. For single older adults, the pandemic compounded existing isolation and foreclosed casual opportunities for meeting potential partners.

Digital forms of intimacy — video calls, texting, and in some cases video-assisted sexual contact — became more prominent. Older adults who had not previously used smartphones or video platforms found themselves rapidly adapting. Self-pleasure as a coping mechanism for pandemic isolation was discussed openly in several mainstream media outlets, including the Senior Planet platform, with advocates noting that solo sex is one of the safest forms of sexual expression available and requires no partner to be at risk.

Viagra, Erectile Dysfunction Medications, and Their Cultural Impact

Sildenafil (Viagra) came to market in 1998. Originally developed as a blood pressure treatment, it was found to have the side effect of facilitating and maintaining erections, and it became one of the fastest-selling medications in FDA history. Its approval and commercial uptake reflect the cultural significance placed on erectile function and penetrative sex, particularly for older men.

More than twenty years of PDE-5 inhibitors (phosphodiesterase type 5 inhibitors — the drug class to which Viagra, Cialis, and Levitra belong) have produced a complex legacy. On one hand, these medications have extended the sexual lives of many men and their partners, and have contributed to a more open cultural conversation about erectile function. On the other hand, they have reinforced a cultural equation between male sexuality and penile erection, potentially marginalizing men who do not respond to medication or who prefer non-penetrative sexual expression.

A less frequently discussed dimension is the perspective of partners. Many older women whose male partners began using erectile dysfunction medication found themselves in a situation where penetrative sex — which they may have experienced as uncomfortable or painful due to vaginal dryness, GSM (genitourinary syndrome of menopause), or other changes — was suddenly back on the table after years of absence. The assumption embedded in the Viagra narrative is that restoring erectile function is an unambiguous benefit to couples, but this assumption overlooks the preferences, comfort, and sexual autonomy of partners.

Chapter 4: Dating and Relationship Formation in Later Life

The Contemporary Landscape for Older Adults

For many adults, later life brings a return to the dating world — through divorce, widowhood, or the end of long-term partnerships of other kinds. This re-entry occurs in a social and technological landscape that may be radically different from the one they navigated in their twenties or thirties. Online platforms, changed gender norms, different bodily realities, and the emotional freight of loss all shape the experience.

Writing in The Atlantic (2020), journalist Megan Garber described the particular character of dating in midlife and later: the simultaneous weight of history and the lightness of fewer pretensions; the more explicit awareness of mortality that sharpens appreciation for connection; the complex interplay of desire and grief for those who have lost partners. Older daters often report that they know themselves better than they did at twenty, but also that they carry more scar tissue — from prior relationships, from illness, from loss — that complicates new intimacy.

The demographic realities of later life shape the dating landscape unevenly. Older women substantially outnumber older men in most Western countries, which means heterosexual women face a smaller pool of potential partners while heterosexual men may find the situation reversed from their younger years. For LGBTQ+ older adults, the dating landscape carries additional layers of complexity related to visibility, community size, and the history of marginalization.

Age-Gap Relationships

Social attitudes toward age-gap relationships are notably asymmetric by gender. Older men partnering with younger women is culturally normalized and even expected; older women partnering with younger men (sometimes called “cougars” in popular media) is treated as exceptional, transgressive, or comic. Gollayan (2017) examined older women/younger men pairings and found that participants reported both significant social stigma — from family, peers, and strangers — and a range of personal advantages: energetic partners, reduced gender-role traditionalism, and freedom from scripts about who should initiate or lead in a relationship.

Power dynamics in age-gap relationships are multidimensional. The older partner may carry more financial and social capital, while the younger partner may carry physical vitality and social desirability. These asymmetries are not inherently problematic, but they warrant awareness. The course invites students to apply an intersectional lens: the dynamics of an age-gap relationship look very different depending on the genders, races, and socioeconomic positions of the partners involved.

Living Apart Together (LAT)

Living Apart Together (LAT) is an increasingly recognized relationship structure in which committed partners maintain separate households by choice. LAT is most commonly discussed in the context of younger adults, but it has particular resonance for older adults who have established autonomous lives, own property, wish to manage separate healthcare arrangements, or who value the psychological space that separate homes provide.

Lewin (2017) compared health and relationship quality across four relationship structures among older adults: LAT partnerships, first marriages, remarriages, and cohabiting (unmarried) partnerships. The findings complicate simple hierarchies of relationship form. LAT partners reported relationship quality comparable to or exceeding that of first-married couples, with particular advantages in autonomy and reduced conflict. However, LAT arrangements may provide less social support in times of illness, and they are less legible to healthcare systems and legal frameworks that assume cohabitation as the default for intimate partners.

Older adults choose LAT for a variety of reasons: to preserve financial independence and avoid complex estate planning; to maintain social and familial identities that are embedded in their own homes; to honour children’s or grandchildren’s emotional ties to a parent’s household; to manage health conditions without burdening a partner in the same space; or simply because they have learned, through long experience, the value of solitude.

Marriage and Cohabitation After 65

Schlesinger and Schlesinger (2008) studied marriage and cohabitation among Canadian-Jewish seniors after age 65, a population shaped by strong religious traditions around marriage and family, distinctive community ties, and particular cultural constructions of widowhood and remarriage. Their findings illuminate motivations that are both universal and culturally specific.

Motivations for marriage in later life include: companionship and the desire to avoid loneliness; practical support in managing daily life and health; sexual intimacy and physical affection; social legitimacy and recognition; and, in some religious communities, the theological significance of marriage as a covenant rather than merely a contract. Cohabitation without marriage is chosen by some older adults as a compromise that provides companionship without the legal and financial complications of marriage.

Family resistance to later-life marriage is a recurring theme. Adult children may worry about inheritance, about the authenticity of a new partner’s motives, or about disruption to established family roles and identities. These concerns are sometimes legitimate, but they can also reflect adult offspring ageism — the paternalistic assumption that an older parent is not competent to make autonomous decisions about intimate partnerships.

Legal and financial considerations are genuinely complex. In Canada, marriage after age 65 can affect pension income, survivor benefits, and estate planning. A late-life marriage without a prenuptial agreement can expose assets accumulated over a lifetime to claims by a new spouse or their family. The course does not counsel against marriage but insists that older adults have access to good legal and financial advice before making such decisions.

Online Dating and Technology

Online dating platforms have transformed the landscape for older singles. Platforms designed specifically for older adults — such as OurTime and SilverSingles — have grown substantially, while mainstream platforms like eHarmony, Match, and even Tinder are used by a significant and growing proportion of older adults.

The benefits of online dating for older adults include: access to a much larger pool of potential partners than social circles typically provide; the ability to specify preferences and filter for compatibility before investing emotional energy; the convenience of connecting from home; and the reduced pressure of asynchronous initial communication. Risks include: exposure to romantic fraud (“romance scams”) that disproportionately target older adults, particularly recently widowed individuals; misrepresentation in profiles; safety concerns around meeting strangers; and the emotional difficulty of repeated rejection or ghosting.

Sexual scripts — the culturally ingrained templates for how romantic and sexual encounters should unfold — can create particular friction for older daters whose scripts were formed in a different era. Questions of who initiates contact, who pays, how quickly physical intimacy is expected, and how to communicate sexual interests may feel unfamiliar when filtered through new platforms and changed social norms.

Chapter 5: LGBTQ+ Aging and Gender Transitions

Unique Challenges for LGBTQ+ Older Adults

Older lesbian, gay, bisexual, transgender, and queer adults face a set of challenges that are distinct from those encountered by heterosexual, cisgender older adults, and that also differ from the challenges of younger LGBTQ+ people. They are a cohort who came of age before the social and legal transformations that began with Stonewall (1969) and accelerated through the AIDS crisis, the decriminalization of same-sex activity, and the legalization of same-sex marriage. Many older LGBTQ+ adults lived significant portions of their lives concealing their identities — from employers, family members, healthcare providers, and sometimes themselves.

This history of concealment and stigma has lasting psychological and physiological effects. Research consistently documents higher rates of depression, anxiety, and substance use among LGBTQ+ older adults compared with heterosexual and cisgender peers, and these disparities are substantially attributable to minority stress — the chronic stress associated with living as a stigmatized minority. At the same time, LGBTQ+ older adults demonstrate remarkable resilience: many developed coping strategies, community networks, and internal resources forged through decades of navigating hostile environments.

Healthcare system distrust is a significant barrier. Many LGBTQ+ older adults have had experiences with providers who were dismissive, hostile, or ignorant of their needs, and who made heteronormative assumptions. Some avoid disclosing their sexual orientation or gender identity to providers even when this information is clinically relevant.

Gender Transitions in Later Life

Fabbre (2015), writing in The Gerontologist, examined the experiences of transgender individuals who underwent gender transitions after the age of 60. This work challenges normative conceptions of both aging and gender transition. The dominant cultural narrative frames gender transition as something that happens in youth or young adulthood — a narrative that erases the experience of people who transition later.

Fabbre’s qualitative research found that later-life gender transitions were motivated by diverse factors: the death of a spouse who had known the person in their pre-transition identity; retirement from a career that had required identity concealment; a sense, at the end of life, that there was no longer anything to lose; or simply the accumulation of self-knowledge that made transition feel both necessary and possible. Participants described their transitions as acts of profound self-actualization — not despite their age but in relationship with it.

These transitions also posed challenges. Older bodies present different medical realities for hormone therapy and surgical procedures. Social networks of long standing may not survive disclosure. Adult children or grandchildren may resist. Healthcare providers may be unfamiliar with the needs of older trans patients. Institutional settings — retirement homes, long-term care facilities — may be ill-equipped to respond appropriately.

Fabbre’s work contributes to a queer perspective on successful aging, which resists the mainstream gerontological model of “successful aging” (typically defined by absence of disease, maintenance of physical and cognitive function, and social engagement) as implicitly normative, able-bodied, and heterosexual. A queer model recognizes that aging looks different for people whose lives have been shaped by marginalization, and that success may be defined not by conformity to dominant ideals but by authenticity, community, and resistance to erasure.

Staying Out of the Closet: Fears About End-of-Life Care

Wilson, Kortes-Miller, and Stinchcombe (2018) conducted qualitative research with LGBT older adults about their hopes and fears regarding end-of-life care. The central finding was a profound and well-grounded fear of re-closeting — the experience of having to conceal or suppress one’s sexual orientation or gender identity upon entering an institutional care setting in order to avoid discrimination, hostility, or poor care.

This fear is not hypothetical. Research documents experiences of care provider homophobia and transphobia, including verbal hostility, refusal of care, neglect, and the erasure of chosen family. Staff may assume heterosexuality, use incorrect pronouns, remove photographs of same-sex partners from residents’ rooms, or fail to include chosen family members in care discussions. For LGBTQ+ residents with dementia who cannot consistently advocate for themselves, these risks are compounded.

The study also illuminated the tension between biological family and chosen family in substitute decision-making. Many LGBTQ+ older adults have established deep networks of chosen family — friends, former partners, community members — who function as their primary support system. Yet legal frameworks for substitute decision-making in Canada and many other jurisdictions privilege biological family, which may exclude chosen family and may even give decision-making authority to estranged relatives who are hostile to the resident’s LGBTQ+ identity.

Historical Cohort Effects and Resilience

Understanding LGBTQ+ older adults requires attention to the historical cohort in which they came of age. Older LGBTQ+ adults who are now in their seventies and eighties were young adults before Stonewall, before the decriminalization of homosexuality in Canada (1969), and before any legal recognition of same-sex relationships. Many experienced or witnessed the AIDS crisis, which decimated gay male communities and was met with governmental neglect and public hostility. This history shapes their relationship to institutions, to disclosure, and to community.

Resilience factors identified in the research include: strong community ties forged through shared adversity; the skills developed through decades of navigating hostile environments; a sense of hard-won self-knowledge and authenticity; and, for many, a spiritual or philosophical orientation that locates meaning beyond social approval.

Chapter 6: Dementia, Consent, and Sexual Capacity

Sexual Expression as a Fundamental Need

Sexual expression and the desire for intimacy do not disappear when a person develops dementia. Research consistently documents that people with dementia continue to experience desire, to initiate physical contact, and to seek emotional closeness. These expressions of sexuality are manifestations of a fundamental human need — one that does not require an intact memory to be real and legitimate.

Yet the intersection of dementia and sexuality creates profound ethical, legal, and practical challenges. When cognitive function is impaired, questions arise about whether a person can consent to sexual activity, whether their expressed desires reflect authentic preferences or are artifacts of cognitive disruption, and how care staff and institutions should respond. These questions have no simple answers.

Legal Frameworks for Sexual Consent Capacity

Bartlett (2010), writing in the Liverpool Law Review, provides an authoritative analysis of the legal dimensions of sexual consent and dementia in the UK context, with implications for Canadian and other common-law jurisdictions. The central legal question is: what cognitive capacity is required to consent to sexual activity?

The legal standard for sexual consent is lower than for financial or medical decisions: a person need not understand all possible consequences, only the basic nature of the act and that they have the right to refuse. This means that a person with mild or even moderate dementia may retain capacity to consent to sexual activity while having lost capacity to manage finances or make complex medical decisions.

Bartlett’s analysis also addresses the unwise decision principle: that having the capacity to make a decision includes the right to make decisions others consider unwise. A person with dementia who chooses to form a new romantic relationship is not necessarily incapacitated by virtue of making a choice their family finds inappropriate. English law, and increasingly Canadian law, starts from a presumption of capacity that must be rebutted by evidence.

UK case law analyzed by Bartlett revealed significant inconsistency in how courts, care homes, and families approached these cases, with a general tendency toward over-protection — restricting the sexual autonomy of persons with dementia more than the law required — often driven by institutional risk-aversion rather than genuine incapacity findings.

The Impact of Dementia on Couples and Intimacy

Holdsworth and McCabe (2018) conducted qualitative research with couples in which one partner had dementia, examining how the condition reshapes intimacy, sexual expression, and relational identity. Their findings reveal that dementia does not affect sexuality in isolation; it transforms the entire relational context in which intimacy occurs.

Partners in caregiving roles described a complex and painful shift in relational dynamics. The person with dementia may no longer recognize the caregiving partner as their spouse or partner, may express sexual interest toward other people, may initiate sexual contact at times or in ways the caregiver finds difficult, or may become withdrawn from all physical contact. Caregivers described managing the grief of losing their partner as a relational equal while that person was still physically present — a phenomenon described in the literature as ambiguous loss: grief for a person who is simultaneously present and absent.

Sexual activity between partners where one has dementia involves ongoing negotiation of consent. Many caregiving partners described stopping all sexual activity at a certain point in the dementia progression, not because their partner showed no interest, but because they themselves felt uncertain about the validity of consent and uncomfortable with the power asymmetry. Others continued sexual intimacy in modified forms — cuddling, kissing, holding — that felt less ethically fraught.

Institutional Policies and Care Practice

Most long-term care homes lack written policies on resident sexuality, leaving staff to navigate profoundly difficult situations without guidance. Staff discomfort with resident sexuality is widely documented: many care workers have not received training in this area, bring personal values that may lead them to restrict or discourage sexual expression among residents, and are uncertain about their legal obligations.

Family members add another layer of complexity. Adult children of residents may object to their parent forming a new romantic or sexual relationship, whether out of genuine concern about exploitation, grief at seeing a parent partnered with someone other than their deceased parent, or discomfort with parental sexuality. Institutions may capitulate to family pressure in ways that override residents’ rights.

Ethical frameworks for navigating these situations include: the dignity of risk principle (which holds that the right to take risks is part of human dignity, and that eliminating all risk from a person’s life is itself a harm); person-centred care (which treats the preferences, history, and identity of the person rather than the convenience of the institution as the guide for care decisions); and an autonomy-centered analysis that asks what restrictions are genuinely necessary to prevent serious harm.

Chapter 7: Friendship, Grandparenting, and Social Bonds

Friendship in Later Life

Friendships in later life have distinctive qualities that differentiate them from friendships in earlier stages. Edward (2016) conducted qualitative research on friendship in old age, finding that late-life friendships are often characterized by a depth of shared history that creates a particular kind of intimacy — one rooted in mutual witness across decades of change. Friends who have known each other through multiple life transitions, through losses and recoveries, through the changes that aging brings to the body and to social roles, possess a kind of relational knowledge that is not easily replicated.

At the same time, older adults face a characteristic pattern of friendship loss. The death of close friends is a form of bereavement that is often disenfranchised — socially unrecognized, uncelebrated by ritual, and absent from formal grief support structures that tend to focus on the loss of spouses and family members. The cumulative loss of close friends across a decade can produce a profound social thinning that is difficult to communicate to younger people who have not yet experienced it.

Health disparities among friends of similar age create another challenge. When one friend develops serious illness or disability, the friendship must adapt — often toward greater asymmetry in support, with the healthier friend taking on a caring role. This asymmetry, while it can deepen intimacy, can also generate guilt (in the ill friend), fatigue (in the healthy friend), and eventual distance.

The capacity to form new friendships in later life is genuine but constrained by the social contexts available for meeting people. Senior centres, faith communities, continuing education programs, volunteer organizations, and hobby groups all serve as sites of new friendship formation. Research suggests that older adults who make such connections report significantly higher levels of well-being than those who rely solely on existing social ties.

Grandparenting and Intergenerational Bonds

Mansson (2016) conducted qualitative analysis of grandparenting as a source of joy, meaning, and identity in later life. Grandparents in the study described the grandparent role as one of the most significant sources of purpose in their later years, while also noting its distinctive character — different from parenting in both the quality of attention it demands and the degree of freedom it offers.

Grandparenting styles vary along several dimensions: the degree of direct involvement in childcare, the emotional tone of interaction (warm and playful vs. authoritative and mentoring), the extent to which grandparents share cultural heritage, stories, and values, and the management of geographic distance. The growth of geographically dispersed families has created both challenges (less opportunity for spontaneous contact) and adaptations (video calling, social media sharing, extended visits).

Intergenerational relationships benefit both older adults and children and grandchildren. For older adults, grandchild relationships provide connection to the future, a reason to stay current with cultural change, and the distinctive pleasure of loving and being loved without the anxious weight of primary parental responsibility. For grandchildren, relationships with grandparents provide connections to family history, exposure to a different pace of life, and sometimes a source of unconditional positive regard that complements the more conditional dynamics of parent-child relationships.

The digital divide — the gap between those who are comfortable with digital technologies and those who are not — plays out in interesting ways in intergenerational relationships. While older adults are often characterized as technologically behind, many grandchildren take pleasure in serving as reverse mentors: teaching grandparents to use smartphones, social media, or video platforms. This reversal of the usual knowledge gradient can be both practically useful and symbolically important, giving the grandchild a role of competence and giving the grandparent a reason to engage with technology they might otherwise avoid.

Chosen Family and Social Isolation

For many older adults — particularly those who are LGBTQ+, who have estranged biological families, or who have outlived most of their relatives — chosen family is the primary social and support network. Chosen family consists of people who function as family without biological or legal connection: close friends, former partners, community members, and others whose relationship has been deliberately and mutually invested.

Chosen family carries particular importance in the context of aging because it may constitute the care network available in times of illness, the social network available at the end of life, and the community that provides the sense of belonging and recognition that is essential to well-being.

Social isolation and loneliness in later life are significant public health concerns. Research suggests that the health consequences of chronic loneliness are comparable to those of smoking 15 cigarettes per day, and include elevated risk of cardiovascular disease, dementia, depression, and premature mortality. The epidemic of loneliness in older adult populations reflects structural factors — loss of partners, retirement from workplaces, reduced mobility, ageist social norms — that are not merely individual problems but social and political ones.

Technology offers partial solutions — video calling, online communities, social media — but also has limits. The most robust buffer against loneliness is not technology but embodied, in-person contact: physical presence, touch, shared meals, and the texture of daily life with others.

Chapter 8: Long-Term Care and Sexuality

The Institutional Environment

Long-term care homes and other residential care settings impose conditions that are structurally inimical to sexual expression. The loss of privacy is perhaps the most fundamental: residents typically live in small rooms that staff enter without warning, in facilities where sexual activity is neither anticipated nor accommodated in the physical design. The power asymmetry between care staff and residents — who depend on staff for their most intimate bodily needs — creates conditions that make asserting sexual preferences or desires feel risky and sometimes impossible.

The surveillance inherent in institutional care extends to relationships. Romantic or sexual activity between residents may be observed, reported, discussed, and subjected to staff or family intervention in ways that would be unimaginable outside the institutional context. This surveillance is not always malicious; it may be motivated by genuine concern for resident safety and well-being. But its effect is to constitute the sexuality of residents as subject to institutional management rather than personal autonomy.

Ethical Obligations of Nursing Staff

Everett (2008), writing in Nursing Ethics, argued that healthcare professionals in long-term care settings have an ethical obligation not merely to tolerate residents’ sexual expression but actively to support it. This position moves beyond non-interference toward affirmative facilitation of conditions in which sexual expression can occur.

Everett’s framework rests on the principle that sexual well-being is a component of overall well-being and therefore falls within the mandate of person-centred care. Practical implications include: knocking before entering residents’ rooms and waiting for a response; providing “do not disturb” mechanisms that staff are trained to respect; facilitating access to privacy for residents who share rooms with others; educating staff about residents’ rights to sexual expression; and developing institutional policies that establish these rights clearly.

The tension between residents’ sexual rights and institutional liability is real but manageable. Institutions that lack policies on resident sexuality may inadvertently create greater liability by leaving staff without guidance, whereas clear, rights-based policies protect both residents and staff.

Disability, Facilitated Sex, and Nursing Ethics

Earle (2001) introduced the concept of facilitated sex — assistance provided to people with physical disabilities to enable them to engage in sexual activity — into the nursing ethics literature, a move that provoked significant debate. The concept encompasses a range of possible assistance: positioning, the use of adaptive equipment, preparation, and in some international contexts, more direct assistance.

Earle’s work forces a consideration of the assumptions embedded in the nurse-patient relationship and in disability more broadly: that people with disabilities are asexual, or that their sexual needs are less important than other care needs, or that facilitating sexual expression is categorically outside the professional role. Each of these assumptions can be examined and contested.

Talking to Healthcare Providers About Sex

Fileborn and colleagues (2017) conducted qualitative research with older Australians to explore their experiences of discussing sexual health with healthcare providers. The findings documented profound barriers on both sides of the clinical encounter.

From the patient side: embarrassment and shame; the expectation that the provider would raise the topic if it were important; the belief that sexual concerns were not “medical” problems; and, for LGBTQ+ patients, the additional barrier of uncertainty about whether the provider would respond in an affirming way.

From the provider side: ageist assumptions that older patients were not sexually active and therefore did not have sexual health concerns; discomfort with discussing sex with older patients; time constraints; and lack of training in sexual health communication with this population.

The result is a clinical encounter in which sexual health is systematically omitted. This omission has consequences: STIs are diagnosed late, sexual dysfunction goes untreated, relationship problems with sexual dimensions go unaddressed, and medication side effects on sexual function are not discussed. Fileborn’s recommendations focus on providers routinely and proactively raising sexual health in consultations with older patients — normalizing the inquiry in a way that gives patients permission to respond.

Chapter 9: Menopause and Hormonal Change

Defining Menopause

Menopause is defined clinically as the cessation of menstrual periods for twelve consecutive months, marking the end of a person’s reproductive years. The average age of natural menopause in Canada and the United States is approximately 51, though the range is wide (typically 45–55). Perimenopause refers to the transitional period — sometimes lasting several years — before the final menstrual period, during which hormonal fluctuations produce many of the symptoms associated with menopause. Postmenopause refers to the years following menopause. Surgical menopause occurs when the ovaries are removed surgically (oophorectomy), producing an abrupt rather than gradual transition and often more intense symptoms.

The physiological basis of menopause is a decline in the production of estrogen and progesterone by the ovaries as the remaining supply of follicles is depleted. This hormonal shift triggers a cascade of physical changes.

Physical Changes

Vasomotor symptoms — the most widely recognized symptoms of menopause — include hot flashes (sudden sensations of intense heat, often accompanied by flushing and perspiration) and night sweats (hot flashes occurring during sleep, which can significantly disrupt sleep quality). These symptoms can persist for several years and are experienced by the majority of menopausal people, though with wide variation in frequency and severity.

Genitourinary syndrome of menopause (GSM) — formerly called vulvovaginal atrophy — refers to a constellation of changes in the vulva, vagina, and urinary tract resulting from reduced estrogen: vaginal dryness, thinning and decreased elasticity of vaginal tissues, reduced natural lubrication, dyspareunia (painful intercourse), urinary urgency, frequency, and increased susceptibility to urinary tract infections. GSM affects an estimated 50–60% of postmenopausal people to a clinically significant degree, yet is substantially underreported and undertreated.

Other physical changes associated with menopause include: changes in skin elasticity and texture; changes in hair distribution and density; sleep disruption independent of night sweats; mild cognitive changes (sometimes called “brain fog”) that are typically transient; changes in mood, particularly increased anxiety; shifts in libido that may go in either direction; and changes in body composition, including redistribution of fat toward the abdomen.

Menopause as Medical Construction

Newhart (2013) offered a critical examination of how menopause has been framed in medical and public discourse. The medicalization of menopause — treating it as a deficiency disease to be treated with hormone replacement — has implications for how both providers and patients understand it. When menopause is framed as a pathological estrogen-deficiency state, the corollary is that medical intervention is the appropriate response, which shapes both treatment and self-perception.

Newhart’s analysis traced the history of this framing, noting that the “deficiency disease” model became dominant with the widespread introduction of hormone replacement therapy (HRT) in the 1960s and was further entrenched by pharmaceutical marketing. The model obscures the wide variation in menopausal experience — many people experience minimal symptoms and do not perceive menopause as a disorder — and directs attention away from lifestyle, social, and psychological factors that also shape the experience.

Menopause as Cultural Taboo

Chrisler (2013), examining the psychology of women and the teaching of taboo topics, analyzed menstruation and menopause as subjects surrounded by cultural silence, shame, and euphemism. The cultural invisibility of menopause reflects the intersection of ageism and sexism: menopause is associated with the end of reproductivity, which Western culture codes as the end of a woman’s primary social value.

The shame and secrecy surrounding menopause prevent people from accessing accurate information, from seeking treatment for uncomfortable symptoms, and from processing the emotional dimensions of the transition. Education — including the kind provided in courses like SMF 212 — plays an important role in denormalizing this silence.

Post-Menopausal Zest

The concept of post-menopausal zest was originally articulated by anthropologist Margaret Mead to describe the energy and creative vitality she observed in women after menopause. Dodd (2014) updated and expanded this concept for a contemporary audience, arguing that the end of the reproductive phase of life opens possibilities that the years of potential pregnancy, actual pregnancy, and child-rearing had closed.

Freed from concerns about unwanted pregnancy, post-menopausal people may experience a new relationship with their sexuality — one characterized by greater spontaneity, less anxiety, and often a more explicit awareness of their own desires and preferences. The broader social and psychological changes of midlife may also contribute: children launched, careers established or reorienting, a sense of self-knowledge accumulated across decades, and a relationship with mortality that sharpens appreciation for present experience.

The post-menopausal zest concept is not universally applicable — it does not describe the experience of those whose menopause was marked by distressing symptoms, difficult losses, or health crises — but it provides a genuine counter-narrative to the dominant framing of menopause as pure loss.

Hormone Therapy

Hormone therapy (HT) — previously called hormone replacement therapy (HRT) — involves the administration of estrogen, often combined with progestogen, to address the symptoms of menopause. After being widely prescribed for several decades, HT became controversial when the Women’s Health Initiative (WHI) published its landmark study in 2002, which found associations between combined estrogen-progestogen therapy and increased risks of breast cancer, cardiovascular disease, and stroke.

The subsequent years saw a dramatic reduction in HT prescribing, followed by a more nuanced re-evaluation of the WHI data. Current clinical guidance emphasizes that HT risks and benefits depend substantially on the type of hormone, the delivery method, the dose, the timing of initiation (the “timing hypothesis” suggests that HT initiated in the early postmenopausal years carries a more favorable risk profile), the specific symptoms being treated, and individual health history. Non-hormonal options for specific symptoms include selective serotonin reuptake inhibitors (SSRIs) for vasomotor symptoms, local vaginal estrogen (which has minimal systemic absorption) for GSM, and a range of lubricants and moisturizers for vaginal dryness.

Male Hormonal Changes: Andropause

Unlike female menopause, which involves a relatively abrupt hormonal transition, the decline in testosterone production that occurs in aging males is gradual, beginning in the third or fourth decade and continuing across the lifespan. The term andropause — sometimes called “male menopause” — is contested in the medical literature: some clinicians argue that the gradual, variable nature of age-related testosterone decline makes it meaningfully different from female menopause and that the term implies a false symmetry.

The consequences of declining testosterone include reduced libido, decreased muscle mass, increased body fat, reduced bone density, decreased energy, and mood changes including increased irritability and depression. In men with clinically low testosterone levels (hypogonadism), testosterone replacement therapy may be prescribed, with benefits for libido, energy, and mood. However, routine testosterone supplementation for age-related decline in the absence of clinical hypogonadism remains controversial.

Chapter 10: Alternative Living and End-of-Life Planning

Alternative Living Arrangements in Later Life

The dominant model for aging in Western societies — aging in a private family home until a health crisis necessitates institutional care — is neither universal nor inevitable. A growing range of alternative living arrangements offer different balances of independence, community, support, and cost, and have attracted significant interest among aging populations who are dissatisfied with the available options.

Co-housing refers to intentional communities in which residents have private living spaces but share common spaces and some resources, often including meals, gardens, workshops, or care-sharing arrangements. Co-housing communities may be age-integrated (mixing adults of all ages) or age-specific (designed for older adults). They aim to combine the privacy and autonomy of private ownership with the social connection and mutual support of communal living.

Treleaven (2017) examined the case of female seniors in Canada who chose co-living arrangements over traditional retirement homes. Motivations cited included cost (co-living arrangements can be substantially less expensive than retirement homes); companionship on terms structured by residents rather than institutions; the preservation of autonomy in daily life decisions; and a feminist critique of the isolated nuclear-family model as inappropriate for aging. Challenges included: negotiating conflict between residents with different habits and standards; managing health disparities as some residents became more dependent over time; and the practical and legal complexities of shared property.

End-of-Life Planning for Couples

Thomeer, Donnelly, Reczek, and Umberson (2017) conducted qualitative research with gay, lesbian, and heterosexual couples about their planning for future care and end of life. The study illuminated both shared concerns and dimensions of experience that differ by sexual orientation and gender.

All couples in the study faced common challenges: emotional difficulty in confronting mortality, uncertainty about what the future would bring, and the complexity of coordinating two individuals’ preferences, values, and fears in a single planning process. Women in heterosexual couples carried a disproportionate burden of planning work — researching options, initiating conversations, and managing documentation — a pattern that reflects broader gender dynamics in care work.

Same-sex couples faced additional, distinctive challenges. Many had lived through periods in which their partnerships had no legal recognition, and some had already confronted the legal vulnerability of their partnerships during serious illness or the deaths of previous partners. The uncertainty about who counts as next-of-kin — and the possibility that hostile biological family members might override chosen family in healthcare or estate decisions — was a specific source of anxiety.

Advance directives — including living wills, powers of attorney for personal care, and healthcare proxies — are documents through which individuals specify their wishes for care if they become incapacitated. The importance of these documents for LGBTQ+ couples cannot be overstated: without them, biological family members may legally override a partner’s wishes. Their importance for all older adults is substantial, and yet research consistently finds that the majority of older adults have not completed them.

Financial and Legal Considerations

End-of-life planning encompasses not only healthcare but financial and estate planning. For older adults with significant assets, questions of estate distribution, spousal survivor benefits, and the management of finances during a period of incapacity require legal and financial advice.

In Canada, the absence of universal long-term care funding means that the cost of institutional care — which can reach $5,000–$10,000 per month in many provinces — is a major financial concern for older adults and their families. Long-term care insurance is available but expensive and increasingly difficult to obtain for people with existing health conditions. These financial realities intersect with end-of-life planning in ways that shape the options available to older adults of different socioeconomic positions.

Chapter 11: Death, Dying, and the Death-Positive Movement

The Death-Positive Movement

Contemporary Western culture is characterized by a profound discomfort with death. Death is medicalized — treated as a failure to be prevented rather than a passage to be prepared for — and removed from ordinary social life, taking place in hospitals and long-term care facilities rather than at home, managed by professionals rather than by family and community. The cultural silence around death mirrors the silence around aging sexuality: both reflect an unwillingness to confront the realities of the embodied life course.

The death-positive movement is a loose cultural and social movement that seeks to normalize conversations about death and dying, to encourage advance planning, to support people in dying as they choose, and to reconnect death with the rhythms of ordinary life. The movement encompasses: the Order of the Good Death, an organization of funeral directors, academics, and writers who promote death education; the Death Cafe movement, which organizes informal social gatherings to discuss death over coffee and cake; and a growing genre of death-positive writing, podcasting, and social media content.

Dying Together: A Case Study

Van Wijngaarden, Leget, and Goossensen (2016) presented a phenomenological study of an elderly Dutch couple who chose to end their lives together through spousal self-euthanasia. The Netherlands is one of a small number of countries where euthanasia is legal under defined conditions; the case presented by the researchers involved a couple who had lived together for decades and who faced the prospect of one of them dying before the other of serious illness.

The phenomenological analysis illuminated the meanings both partners attached to the decision: the desire to preserve the integrity of a shared life by ending it together; the anticipation of unbearable loss at the prospect of the surviving partner’s solitude; and an understanding of death as the final act of a partnership rather than its dissolution. The case raises profound ethical questions about autonomy, love, suffering, and the social and legal conditions that shape end-of-life choices.

The case is not presented as a model but as a site of ethical reflection. Students are invited to consider the multiple perspectives implicated: those of the couple themselves, of their family and friends, of the medical professionals involved, and of the broader society that creates the conditions — of loneliness, inadequate palliative care, and cultural death-avoidance — within which such decisions are made.

Medical Assistance in Dying in Canada

Canada’s framework for medical assistance in dying (MAID) has evolved rapidly. The Supreme Court of Canada’s decision in Carter v. Canada (2015) struck down the Criminal Code prohibition on assisted dying as inconsistent with the Canadian Charter of Rights and Freedoms, finding that it violated the rights to life, liberty, and security of the person. Bill C-14 (2016) established the initial legislative framework for MAID, limiting eligibility to persons whose natural death was reasonably foreseeable. Bill C-7 (2021) expanded eligibility to remove the “reasonably foreseeable natural death” criterion and created two tracks of assessment: one for those whose death is foreseeable and one for those whose suffering arises from a chronic illness or disability without terminal prognosis.

MAID is distinct from the Dutch model of euthanasia in several respects of eligibility criteria and procedural requirements, though both are premised on the principle that individuals have a right to determine the conditions of their dying.

Grief and Bereavement in Later Life

Later life is characterized by accumulating loss. The death of parents, siblings, lifelong friends, and ultimately partners — sometimes multiple partners — creates a pattern of grief that is distinctive in its cumulative weight and in the ways it intersects with a person’s own awareness of mortality.

Grief in later life is frequently disenfranchised in ways beyond the death of friends: the death of an ex-spouse, of a person whose relationship was not publicly acknowledged (as is common for LGBTQ+ older adults), of a pet who was a primary source of daily companionship, or of a person whose relationship to the griever was complex and ambivalent. Disenfranchised grief lacks the social support structures — bereavement leave, condolence rituals, communal mourning — that accompany recognized loss.

Post-traumatic growth — the experience of positive psychological change following adversity — is documented in bereaved older adults. Some people emerge from significant loss with greater clarity about what matters to them, deepened relationships with surviving loved ones, renewed spiritual engagement, or a more authentic relationship with their own mortality. Post-traumatic growth does not negate grief but can coexist with it.

Intimacy at End of Life

Physical touch and intimacy remain important at the end of life. Palliative care research documents that dying people often long for physical closeness — to be held, touched, and physically accompanied through the dying process — yet institutional settings and family discomfort often leave dying people isolated in precisely the moments when embodied connection matters most.

Honoring intimacy in hospice and palliative care settings involves: creating physical environments that accommodate close, prolonged presence of loved ones; training staff to support rather than interrupt intimate moments; and, where appropriate, facilitating sexual or romantic expression between partners even in the context of terminal illness. The sexuality and intimacy of dying people are among the most neglected domains of palliative care practice.

Chapter 12: Ageism Revisited — Anxiety, Contact, and Change

Returning to Ageism from a New Angle

The final chapter of the course returns to the theme with which it began — ageism — but from a new vantage point. Having moved through the full arc of adult sexuality, relationships, health, care, and death, students are invited to revisit their initial assumptions about aging and to examine not just ageism as a social attitude but the psychological roots of their own relationship to age and mortality.

Barnett and Adams (2018) studied ageism and aging anxiety among young adults, examining the relationships between contact with older adults, knowledge about aging, fear of death, and optimism as predictors of ageist attitudes. Their findings contribute to a more complex understanding of ageism than the simple prejudice model: ageism among young people is not simply ignorance or hostility, but is entangled with existential fear and the psychological need to manage awareness of one’s own mortality.

Aging Anxiety and Terror Management Theory

Aging anxiety — sometimes called gerontophobia in extreme forms — is a fear of one’s own aging rather than a prejudice against older others, though the two often coexist. Research consistently finds that aging anxiety is distinct from ageist prejudice but correlates with it: people who are most afraid of their own aging tend also to be most prejudiced against older adults, possibly because proximity to older people activates mortality salience.

Terror management theory (TMT), developed by Solomon, Greenberg, and Pyszczynski (1989) drawing on the work of Ernest Becker, proposes that much of human culture and social behavior can be understood as a system of defenses against the terror of mortality awareness. From this perspective, ageism — the distancing and derogating of older people — functions as a psychological defense: by defining older people as categorically different, younger people create psychological distance between themselves and the reminder of their own mortality that older people represent.

Barnett and Adams found that contact with older adults, knowledge about the aging process, and optimism all moderated ageist attitudes. These findings have direct implications for the design of educational interventions.

Intergenerational Contact and Knowledge

Intergenerational contact theory — an extension of Gordon Allport’s contact hypothesis — predicts that direct, meaningful contact between members of different groups reduces intergroup prejudice when it occurs under conditions of equal status, common goals, cooperation, and institutional support. Applied to ageism, the theory suggests that young adults who have sustained, meaningful contact with older adults — in family relationships, volunteer settings, or educational contexts — will hold less ageist attitudes than those with little contact.

Research supports this prediction, with some nuance: not all contact with older adults reduces ageism. Superficial or service-oriented contact (e.g., brief encounters in a care setting where the older person is in a position of dependence and vulnerability) may reinforce rather than challenge stereotypes. Meaningful contact — characterized by mutual exchange, shared activity, and recognition of the older adult’s full personhood — is the effective ingredient.

Knowledge about the aging process — including accurate information about the range of sexual, relational, cognitive, and physical experiences in later life — also reduces ageist attitudes and aging anxiety. The course itself is an educational intervention of this kind: students consistently report that SMF 212 changed their assumptions about older adults, their comfort with discussing aging and sexuality, and their intentions to address these topics in their professional and personal lives.

Sex Education Across the Lifespan

Formal sex education has historically been designed for and delivered to young people, with the implicit assumption that sexual learning is complete by adulthood. Fileborn and colleagues (2017) examined the sources of sexual learning for older Australians and found a diverse landscape: peers, healthcare providers, popular media, and, for a small proportion, formal educational resources. Healthcare providers were cited both as important potential sources and as frequently unhelpful — either because they failed to raise sexual topics with older patients or because they responded inadequately when patients raised them.

Freeman, Sousa, and Neufeld (2014) examined beliefs and perceptions about sexuality in later life among undergraduate students — a population relevant to this course. Common misconceptions documented in their research included: the belief that older adults do not experience sexual desire; that physical limitations associated with aging preclude sexual activity; and that sexual health needs in later life are a peripheral concern of healthcare. Educational exposure shifted these attitudes significantly.

The implication is that sex education across the lifespan requires effort at multiple levels: within formal healthcare and educational systems; within popular media and cultural discourse; and within the informal spaces of family and community where most sexual learning actually occurs.

The Role of Young People in Changing Ageist Culture

The course concludes with a reflection on the role that young people — including the students in SMF 212 — play in perpetuating or challenging the cultural conditions that shape aging. Ageism is not merely the prejudice of individuals; it is embedded in institutions, in media, in language, and in the design of social systems. Changing it requires more than changing individual attitudes; it requires changing the systems and cultures that reproduce ageist assumptions.

Young people are agents in this change in several specific ways: as future healthcare professionals who can bring age-competent practice to their work; as family members who can engage older relatives with curiosity and respect rather than condescension or avoidance; as citizens who can advocate for policy changes that support older adults’ autonomy, dignity, and sexual health; and as cultural participants who can choose not to laugh at ageist jokes, not to use aging as an insult, and not to treat older adults as a category rather than as full human beings.

Closing Reflections on the Course

SMF 212 is unusual among university courses in the directness with which it confronts its subject. Sexuality is rarely discussed in the context of aging; aging is rarely discussed in the context of sexuality; death is rarely discussed in the context of either. By bringing all three into sustained conversation, the course creates conditions in which students can encounter aspects of human experience that formal education typically avoids.

The sex-positive, intersectional, critically engaged stance that Jacobs brings to the material is itself a pedagogical and ethical stance: a refusal to treat certain bodies, certain desires, certain relationships, or certain stages of life as less worthy of serious attention. The consistent message across all twelve chapters is that human beings are sexual beings across the full lifespan, that this sexuality deserves respect and support from individuals and institutions alike, and that building a society that genuinely honors this truth requires confronting the ageism, sexism, heterosexism, and discomfort with mortality that currently make such honor rare.