National Louis University
Research Evaluation & Methodology
Summer 1998
Dr. Christopher Clemmer
Group project by: Joyce Sweeney, Trish Anderson, Linda Israel, Marissa Green, Debbie Anthony
Introduction
The problem: will Viagra have a negative impact on the emotional relationships of older Americans? AARP discourages the use of the term elderly and uses, instead, the term older Americans, young seniors, and older seniors. This concept is also supported by Journals on Gerontology. This project has taken us into some old and new territory. We chose this topic because of its challenge, and our belief in the value of working collaboratively to mirror an actual research project. We were not disappointed.
Sex in the “golden year” has been a mystery, if not a surprise. Today’s older Americans grew up in a time when sex, at any age, was a secret. As gerontologist Ruth Weg states, “Anyone can be sexually responsive given adequate stimulation, but genital response is only one measure of the total sexual experience” (1). In other words, physiologically aging need not hamper sexual activity, more sexually significant may be one’s feelings about one’s self and one’s mate, one’s expectations, general physical condition, alcohol and drug intake, mood, living situation, ability to communicate about sex, and whether one has a partner.
“Sexuality is very much tied to the rest of the culture,” states anthropologist Jay Sokoowski, of the University of Maryland, “Among the Asisataic Indians, where women are repressed, sex represents male domination and women embrace menopause as an excuse not to engage in sex. On the other hand, he states, in socially equalition cultures, such as the South Pacific Islands, sex is openly discussed from childhood, it is engaged in for pleasure as well as procreation, and it continues, for both men and women throughout life” (2).
In our society, sexuality, in older people, has been the object of ridicule and pity. The underlying assumption is that continued sexual desire is pathetic and inappropriate, since sexual function, we have assumed, is diminished and unsatisfactory. In the late 1940’s Kinsey blew this myth wide open and opened the door to questioning this concept, through his Kinsey Report. In 1970, Masters and Johnson, emotional issues rather than organic problems are the main cause of impotence. Their treatment programs focused on appropriate sex information and facilitating verbal, emotional, and physical communication with the older sex partners. Health problems of older individuals have often been dismissed as unavoidable by products of aging, or treated with drugs that have had a negative impact on the psyche or have led to impotence – generally considered insignificant in older people by the medical professions.
Our paper will explore the available research on Viagra and the theoretical underpinnings of our question, “will Viagra have an impact on the emotional relations of older people?” Our research, via a review of the literature, and interviews with people in the medical field, has provided us with a historical sketch of Viagra since it became available to Americans in March of 1998. We find that our research has raised more questions than it has answered and strongly indicate a need for additional study. As time progresses, and we have the opportunity for analysis of further research, we will have more credible statistics to support or disprove our hypotheses, that Viagra does have emotional consequences for older Americans. The data, available at this time, indicates that some harm is apparent and is consistent with the need for supplemental investigation.
Literature Review
Myths & Taboos
Meredith E. Drench and Rita H. Losee (1996) explored sexuality, psychosocial issues, and sexual capacities of older adults (sixty five and older) in connection with the rehabilitation nurse’s role in providing sexual counseling. Despite many deeply ingrained stereotypes, many elders can and do have sexual enjoyment (Drench & Losee 1996; Richardson 1995). Our society has internalized images of older adults as slow moving and sweet (Drench & Losee 1996). Joan P. Byers (1983) discussed a survey of health professionals in which they used the following phrases to describe sex among the elderly: hard to imagine, nonexistent, discouraged by society, normal, impossible, slow, healthy, and, not very often. People erroneously assume that older adults: don’t desire sex, couldn’t do it if they wanted to, are too fragile physically and might hurt themselves, are unattractive and undesirable sexually, and the thought of older adults being sexual is perverse (Byers 1983). Elderly men are the blunt of jokes and often referred to as dirty old men (Byers 1983; Semmens 2 1997). Women who were once considered attractive girls, and mature interesting women are cast into sexual oblivion after fifty (Byers 1983; Richardson 1995).
Older adults who deviate from internalized taboos against their having a continuing appetite for and ability to maintain sexual relations are seen as abnormal or foolish (Drench & Losee 1996). This lack of understanding and insensitivity can lead to frustration and conflict among older people (Drench & Losee 1996). The notion that aging automatically means a loss of sexuality distorts our attitudes, norms, and values and can cause older adults to miss out on the physical contact they need (Drench & Losee 1996). Some older adults may repress their sexual feelings simply to avoid the disapproval and rejection as a result of taboos and stereotypes (Drench & Losee 1996).
In the nineteen sixties and early seventies, many long term care facilities actually restricted contact between the sexes to public areas so they could be monitored by staff (Byers 1983). Even married older adults were separated and if a spouse visited they were seldom allowed privacy (Byers 1983). These practices were unjust and required older adults to conform, give out their sexuality, and suffer with feelings of guilt because of remaining sexual feelings (Byers 1983).
Medicare guidelines now require nursing homes to provide private spaces for married couples (Drench & Losee 1996; Byers 1983). Some long term care facilities provide privacy for men and women whether they’re married or not (Drench & Losee 1996). Despite this progress, the sexuality of older clients still sometimes conflicts with attitudes of healthcare workers (Drench & Losee 1996).
Women’s Physical Changes
Aging brings a gradual decrease in the duration and intensity of physiological responses to sexual stimulation requiring more and longer stimulation during intercourse (Byers 1983; Richardson 1995). However, all four phases (excitement, plateau, orgasm and resolution) of sexual response still occur (Byers 1983). Orgasms may be shorter, less intense and might take longer to accomplish (Drench & Losee 1996; Richardson 1995). Unlike the male refractory period which increases, women can become aroused again without delay (Drench & Losee 1996).
Masters and Johnson’s studies showed that the main physical changes that aging females experience is due to losses of estrogen (Byers 1983; Semmens 1 1997). With age vaginal mucosa thins, lubrication diminishes, the vagina loses some elasticity and expansion, and shrinks in length and width (Drench & Losee 1996; Byers 1983). If intercourse is infrequent it could be uncomfortable (Drench & Losee 1996). Hence use it or lose it does apply here.
To continue sexual activity one needs to maintain regularity, be interested, and have emotional involvement among the partners (Drench & Losee 1996). Maintaining sexual relations also has some positive physical effects for older women: it helps maintain muscle tone, reduces the incidence of mild urinary incontinence, and regular sexual experience helps to retain their ability for multiple orgasms (Drench & Losee 1996).
Men’s Physical Changes
Although the decrease in testosterone is slight compared to women’s great drop in estrogen, reduced secretions from the seminal vesicles and the prostate gland causes the semen to thin and reduces the amount of ejaculate (Drench & Losee 1996). Sperm remain active and can still be present in advanced age (Drench & Losee 1996). Older males have less ejaculatory tension, sexual flush, and perspiration which may lessen the intensity of pleasure, but doesn’t prevent sexual function even to age ninety (Drench & Losee 1996).
Older males need increased physical stimulation and time to get an erection (Drench & Losee 1996; Richardson 1995). After sixty, men are slower to get an erection, in penetrating a partner, and in ejaculating (Byers 1983). Erection is also lost faster after orgasm (Drench & Losee 1996. There is a greater time delay for recovery (hours or days) before older males are able to become erection again (Drench & Losee 1996; Richardson 1995). As men age there’s a greater frequency of intercourse without ejaculation along with less powerful ejaculation (Drench & Losee 1996).
According to the National Institutes of Health, erectile dysfunction is a myth of aging (Drench & Losee 1996). Potency is measured by erection not ejaculation and males don’t loose this ability solely through aging (Drench & Losee 1996). Men without partners are more likely to experience potency problems, many widowers regain their erectile function when they remarry (Drench & Losee 1996). Masters and Johnson found that the changes in aging males are quantitative rather than qualitative when compared to younger males (Byers 1983). The advantages are that older men can have better control of ejaculation and because arousal is slower, foreplay can be more leisurely (Byers 1983; Richardson 1995). From a partner’s point of view this can be a positive change. Men’s sexual responsiveness does decline, but the availability of partners and retention of youthful attitudes are significant factors in maintaining interest and activity (Drench & Losee 1996).
Psycho/Social Factors
Psychological factors in decreasing potency include: guilt or feelings of inadequacy, self-doubt, lack of knowledge, worries about masturbation or infidelity, fear of failure, fatigue, depression, boredom, worry over money, and the pressure to conform with cultural taboos about sex and aging may impact potency (Drench & Losee 1996). The mistaken notion about sexual activity being harmful after a heart attack, a hysterectomy, or a prostatectomy may also put a damper on one’s sex life (Byers 1983; Semmens 2 1997; Carter 1997).
Sexuality isn’t only about the physical act itself, it’s about love, caring, sharing and warmth expressed from one person to another; it helps us feel secure and comfortable (Byers 1983). Sexual appeal isn’t just about physical attraction, it’s includes assurance of one’s worth, validity, and ability to be loved (Drench & Losee 1996). These feelings can be extremely meaningful to older adults who have experienced many losses (Byers 1983).
A older adult experiencing depression is likely to have a decline in sexual interest and potency, but may erroneously attribute these symptoms as a natural part of the aging process (Drench & Losee 1996). For others, the nearness of or the risk of death may actually heighten sexual desire, which can then lead to guilt and shame (Drench & Losee 1996). A common cause of stopping sexual activity is the loss of a partner (Drench & Losee 1996). Enduring grief can preclude the pursuit of a new partner combined with the loss of confidence and familiarity, making new relationships threatening (Drench & Losee 1996). Many widows and widowers might not have been sexually active with their deceased partner for a long time, making it that much harder to start a new sexual relationship (Drench & Losee 1996). Older adults have had long experience with sexual taboos which can make it hard for them to talk about their sexual desires (Drench & Losee 1996). However, older men have had time to overcome inhibitions and have gained experience with lovemaking skills (Byers 1983).
Many factors can be involved in erectile dysfunction: lack of practice, unfamiliarity with a new partner, guilt, performance anxiety, diminished vascular flow, or delayed neurological reflexes which can then result in decreased self esteem and confidence (Drench & Losee 1996). Older widows have less sex after the loss of their partner than younger widows, but the sexual desire doesn’t differ by the age when one is widowed (Drench & Losee 1996).
Within our youth focused culture, older adults, especially women, are perceived as having lost sex appeal and are labeled as asexual (Drench & Losee 1996). Thus older women become self-conscious about their bodies which makes them avoid sexual contact (Drench & Losee 1996). Our society has focused on older adults who are sick and poor, rather than on the majority who are productive and healthy (Byers 1983). Youth oriented culture scorns signs of aging, seeing it as pathological rather than natural process, with hope that they can somehow prevent it in themselves (Byers 1983).
Drench and Losee (1996) assert that rehabilitation nurses play an important role in helping clients cope with age related changes. Sexual counseling provided for younger clients also needs to be provided for older adults (Drench & Losee 1996; Byers 1983). The rehabilitation nurse needs to be knowledgeable about sexual physiology, sexual needs, myths about elderly sexuality and be aware of their own and their older client attitudes and values around sexuality because older adults can be influenced by the attitudes of health professionals (Drench & Losee 1996; Byers 1983). (An implication for counseling is easily seen in this regard.) Patient education in a psychologically safe atmosphere is vital to discuss intimate issues such as fantasies, masturbation, and homosexuality which may need to be dealt with (Drench & Losee 1996; Byers 1983). A major role of the health professional may be in dispelling myths (Drench & Losee 1996) and assuaging guilt or moral apprehension (Byers 1983). Sexuality and its expression can enhance quality of life and is beginning to be recognized as an important part of the interpersonal relationships among older citizens (Drench & Losee 1996).
Studies
Byers (1983) discussed research done by Kinsey and others at the Center for the Study of Aging at Duke University. Although the elderly were only a small part of Kinsey’s study, they found that at sixty most males were capable sexually and women weren’t found to decline sexually until very late in life (Byers 1983). Longitudinal studies at Duke examined two hundred and fifty people age sixty to ninety four every three years over more than twenty years (Byers 1983). Fifteen percent of these people actually increased their sexual activity and interest as they aged (Byers 1983). Masters and Johnson’s research included interviews and observation of sexual acts (Byers 1983). Both researchers found that people in good health were able to enjoy sex beyond their seventies (Byers 1983). An older couple with a history of a good sex life is more likely to maintain vigor and interest, and is more likely to continue sexual activity with aging (Drench & Losee 1996; Byers 1983; Richardson 1995).
When a problem of sexual functioning does occur its cause usually fits within the following categories:
-monotony in a repetitious sexual relationship
-mental or physical fatigue
-overindulgence in food or drink
-preoccupation with career or economic pressure
-physical or mental issues with one of the partners
-performance anxiety relating to any of the above (Byers 1983).
One episode of impotence can alarm an older man so much that it discourages further attempts (Byers 1983). A prolonged illness of either partner can contribute to impotency (Byers 1983). Widowers may feel too guilty to remarry after the loss of their wife which may cause sexual difficulties (Byers 1983).
Although there are only a few studies of sexuality among older adults, one interesting study was done in nineteen eighty eight among upper middle class residents in ten California life-care communities (Richardson 1995). To be eligible for the study respondents couldn’t be on any regular medications or have daily medical or nursing needs (Richardson 1995). Although the average age of participants was eighty six, seventy percent of the males and fifty percent of the females thought often or very often about being close to or intimate with the opposite sex (Richardson 1995). Despite the fact that twenty nine percent of the men and fourteen percent of the women were married, fifty three percent of men and twenty five percent of women had regular sex partners (Richardson 1995).
Another study, with two hundred and fifty residents in fifteen nursing homes, found that although ninety one percent of the residents hadn’t been sexually active in the previous month, seventeen percent wanted to be, if they had a partner and the privacy to be active (Richardson 1995). Despite some physical changes, older adults can and do continue, sexual interest and capacity even into the their nineties (Drench & Losee 1996).
The Meaning of Life
Patricia M. Burbank’s nineteen ninety two exploratory study explored the meaning of life among older adults. Most of us think of the meaning of life as an important, but elusive concept from the domains of philosophy and theology (Burbank 1992). However, the meaning of life is a major concern to many nurses. Burbank (1992) cites J. Fitzpatrick (1983), “Those who have no meaning do not continue to live” (3) and posited that the meaning of life is intimately connected to our health. Studies have found a positive connection between depression and the loss of meaning in life which the authors view as a mental construct and a primary motivational life force (Burbank 1992).
The theoretical framework that guided Burbank’s (1992) study was symbolic interaction, which is a broad perspective within social psychology, useful in understanding people’s behavior in society. Meaning is seen as the central notion in symbolic interaction and refers to the meaning of symbols and situations (Burbank 1992). Rather than simply responding to events and situations, people give them meaning, and our responses are based on those meanings (Burbank 1992).
Burbank (1992) administered a questionnaire to eighty one older adults over sixty two (most respondents were White females in their mid seventies) who were affiliated with a senior center, some were home bound and required assistance to complete the questionnaire (The Fulfillment of Meaning Scale which is a likert type scale) (Burbank 1988). The study found that within a symbolic interaction perspective relationships are vital (Burbank 1992). Interaction with others is how we define situations and our meanings stem out of these situations, thus making relationships and interaction crucial to how we give and maintain meaning to situations (Burbank 1992). The majority of participants said relationships were what gave meaning to their lives (Burbank 1992). Burbank (1992) recommends that nurses become more aware of what’s meaningful to older adult clients and plan nursing interventions in ways that support or improve meaning for their clients (Burbank 1992). If life holds meaning through relationships, what happens when Viagra is added to the relationships of older adults?
And Then There Was Viagra …
Viagra, whose chemical name is sildenafil citrate is manufactured by Pfizer Labs, Inc (Pfizer 1998). Viagra is indicated for erectile dysfunction (Pfizer 1998). At recommended doses, Viagra has no effect without sexual stimulation (Pfizer 1998). It’s metabolized by the liver and is excreted mostly as metabolite in feces (Pfizer 1998). It’s absorbed orally with maximum plasma concentrations in thirty to one hundred twenty minutes (Pfizer 1998). If taken with a high fat meal absorption is slower (Pfizer Labs 1998). In eight double blind, placebo controlled crossover studies with patients with organic and psychogenic erectile dysfunction, sexual stimulation resulted in improved erectile ability as assessed by penile plethysmography after Viagra compared to placebo (Pfizer 1998). Most studies tested after sixty minutes (Pfizer 1998). Single doses of up to one hundred milligrams failed to produce electrocardiographic changes in normal male volunteers (Pfizer 1998).
Clinical studies assessed its effect on the abilities on men with erectile dysfunction to engage in sex and in many cases specifically to achieve and maintain an erection sufficient to perform satisfactory sexual activity (Pfizer 1998). Clients using Viagra demonstrated statistically significant improvement when compared to placebo in all twenty one studies (Pfizer 1998). At the end of the long term study (one year) eighty eight percent reported improved erections (Pfizer 1998). A review of the population subgroups showed efficacy regardless of baseline severity, etiology, race, or age (Pfizer 1998). Viagra was effective in patients with histories of coronary artery disease, coronary artery by pass surgery, high blood pressure, peripheral vascular disease, diabetes, radical prostatectomy, prostatic trans-urethral resection, depression and antidepressant or antipsychotic drugs, spinal cord injury, and antihypertensive, or diuretic drugs (Pfizer 1998).
A thorough medical history with physical exam are recommended to diagnose erectile dysfunction, determine its cause, and identify appropriate treatment before prescribing (Pfizer 1998). There is a degree of cardiac risk involved in sexual activity, thus it is suggested that physicians consider cardiovascular status prior to prescribing Viagra (Pfizer 1998). The most common side effects were reported from long term (over one year) studies in order of frequency are: headache, flushing, dyspepsia, nasal congestion, and urinary tract infection (Pfizer 1998).
For most patients the recommended dose is fifty milligrams, taken as needed, one hour before sexual activity, but may also be taken from thirty minutes to four hours before sex (Pfizer 1998). Dosage may be increased up to one hundred milligrams or decreased to twenty five milligrams (Pfizer 1998). The maximum dosage frequency is once a day (Pfizer 1998).
Popular Media Coverage
Popular magazines, newspapers, television, and talk radio shows abound with information and articles on Viagra. A New York Times article (May 1998), suggested that marriage and sex counselors are uneasy about men overhauling their sex lives without any guidelines regarding the potential earthquake they may be introducing into their emotional lives (Nordheimer 1998).
A Washington Post article (May, 1998) suggested that Viagra may have a downside for some couples (Wee 1998). One woman said she and her husband had sex five nights a week in their twenties, but after thirty three years of marriage, they might have sex on Saturday nights if they’re not too tired (Wee 1998). Although they may go weeks without sex, they still enjoy it once they get going (Wee 1998). They now have a deep and comfortable relationship without the sex (Wee 1998). The article relates the view of urologist, Myron Murdock, National Medical Director of the Impotence Institute of America (involved in Viagra clinical trials), who warns, that as time passes, we’re going to see some complex psychological things happening in the relationships of patients using Viagra (Wee 1998). Murdock predicts that some impotent men will discontinue Viagra due to the increased stress and anxiety that sex adds to their relationships, stress and anxiety they’re not able to cope with (Wee 1998).
A Chicago Tribune (May 1998) article questions what effect the “Viagra frenzy” (4) might have in marital bedrooms where sleep has been the primary activity for years (Condor & Black 1998). For the men Viagra has helped and for Pfizer stockholders, Viagra is a sweet miracle (Condor & Black 1998). But the article asks, as we do, what issues about aging and sexuality in our American culture is Viagra bringing out and how will it effect our senior’s relationships (Condor & Black 1998)? Which brings us to the kinds of questions we would like to ask about Viagra’s effect on the relationships of our grandparents, parents, our future sexual selves, and to our children.
Hypothesis
The main object of our exploratory study is to determine the psychological effects that taking Viagra would have on relationships in elderly couples. The hypothesis is that taking Viagra will have psychological effects on older Americans’ ages 65 and older. Up to date there have been many studies done on the medical and or physical side effects of Viagra. In many of the articles we read the researchers talked about possible physical side effects such as heart problems and possible side effects of taking Viagra in combination with other medicines. From what we found however there has been very little research done on the possible psychological effects Viagra could have on older Americans’ relationships. The psychological effects of a drug are just as important as the physical ones are.
The aging process can be difficult for both men and women, but research has shown that men generally have a more difficult time adjusting to these changes. Men are conditioned throughout their lives to be strong, in control and independent. Men can be particularly devastated by the losses associated with aging, especially their capacity to have a sexual relationship.
Prior to the development of Viagra, older couples just took it for granted that they would no longer have that youthful, passionate sexual experience. Now, Viagra offers these couples a “new lease on life,” or at least some of that lost passion. There are some concerns in the elderly community with regard to health risks as well as mental health risks and taking Viagra.
Dr. Steven Lamm, a teacher at the New York University School of Medicine and is author of The Virility Solution states, “this drug touches the core of malehood” (5). He also states that “some couples are going to be disappointed that this hasn’t enhanced their intimacy, and for many that will throw their relationships out of synch” (5).
There are many possible psychological effects that could take place after taking Viagra. Couples that have not been able to perform sexually for years many times learn to be intimate in other ways other than just sex. In many of the articles we read the couples referred to their relationship as a strong companionship that they have grown to love on a new level. Putting Viagra on the market adds a pressure to one or both partners about having sex again. Many women may also feel pressure to abide by this because of a fear that their husbands may stray from the marriage and have an affair. Another possible psychological outcome could be a great disappointment on the actual effects Viagra will have on a couple.
Another words many people may think that by taking this “magic” pill many of their intimacy and or sexual “issues” will just vanish. Unfortunately a pill can not do that, any underlying intimacy or communication problems that were there prior to taking Viagra will still be there after the fact. If these types of issues are not addressed to couples prior to taking this drug it could potentially cause great anxieties and new “issues” in the relationship.
It does seem hopeful that the psychological effects of Viagra on relationships could in fact be the next step. In one of the articles we read it talked about this being the next step in research. For individuals to truly benefit from this drug the psychological as well as the physical effects should be studied
Our approach is a holistic one that would place equal importance on the mind and body working together. Couples who are thinking of taking this drug need to be aware of the potential negative effects it could have on their relationship if they are taking it for the wrong reasons. For instance if they think that it will help underlying sexual issues of any kind, it won’t. Couples should have a realistic understanding of what Viagra will and won’t do for their marriage. That is not to say that Viagra’s effects are all negative. In fact it is quite the opposite as long as couples know the possible effects. Many experts agree that taking Viagra could in fact be magical, for committed caring couples whose sex life has been put on hold for many years. A way to test our hypothesis would be to give confidential questionnaires to older Americans after taking Viagra. We have documented how we would go about doing this in the next section.
Methodology
We have selected the use of questionnaires as our form of research and data collection. We feel the nature of our questions are very sensitive and people might feel less threatened and more prone to giving accurate information. We will request the medical professional administering the Viagra give an open-end form of the questionnaire to the patient upon initial prescription of Viagra. This will be used as a pretest to form the more closed-end questions we will be using on the research questionnaire. We will request the health professional follow up with the research questionnaire approximately six months to a year after the treatment begins and request their cooperation. They would be accompanied by a post-paid, addressed envelope for return. This would help insure patient confidentiality and anonymity. We will be using two identical questionnaires, one to be completed by the male prescribed Viagra and one completed by his partner. They will be consecutively numbered 1a, 1b, 2a, 2b, etc, so that information can be tracked by couple. By using this split-ballot type questionnaire, we hope to get an accurate picture of the relationship changes, if any, from both perspectives.
Questions will be both closed-ended and open-ended, with a comment section provided at the end of the questionnaire for elaboration. Information requested will include relationship and general health problems prior to Viagra use, and relationship and specific health problems after Viagra use. We will also request information regarding any new effects on health or relationship since Viagra. Questionnaire respondents will be asked if they would be willing to participate in any future interviews conducted. A representative sample of the questionnaire is included at the end of this paper.
SONG
What goes up must come down
If I take Viagra will my life turn around
Talkin bout my troubles is a crying shame
That’s why this Viagra gonna give me some fame
You got no passion … you got no hope
Praying for a miracle so I can cope
Talkin bout my troubles and I never learn
Give me some Viagra, let my maleness return
Chorus:
What if my wife tells me not tonight
When I finally get this erection
What if I can’t perform tonight
I’ll end up in a deep depression …………
Someone is waiting just for me
If it’s not my spouse I’ll pay a fee
Could be a problem, don’t you see
Research for Viagra should include psychology …..…
This is my story, I wanted you to know
What can happen if it starts to grow
I hope and I pray there’ll come a day
When Viagra gonna work for me in every way
Chorus:
What if my wife tells me not tonight
When I finally get this erection
What if I can’t perform tonight
I’ll end up in a deep depression …………
What goes up must come down
If I take Viagra will my life turn around
Talkin bout my troubles is a crying shame
That’s why this Viagra gonna give me some fame
End Notes
1 Weg, Ruth (1989, Sept/Oct). The Biological Facts: Myth Versus Reality. Geriatric Nursing. p. 305.
2 Sokolowski, Jay. (1982, July/Aug). Sexual Behavior of the Aged. Gerontologic Review. vol. 15, pp. 214-215.
3 Burbank, Patricia M. (1992, Sept). An Exploratory Study: Assessing the Meaning of Life Among Older Adult Clients. Journal of Gerontological Nursing. pp. 19.
4 Condor, Bob. & Black, Lisa. (1998, May 3). Couples Adjusting to Life with Viagra. Chicago Tribune. Sec 1, p.5, col 5.
5 Berkowitz, Harry., Vincent, Stuart., & Talan, Jamie. (1998, May 3). Little Pill Big Stir: As Demand for Potent Viagra Grows, So Do Concerns. Newsday, Internet.
Work Cited
Burbank, Patricia M. (1992, Sept). An Exploratory Study: Assessing the Meaning of Life Among Older Adult Clients. Journal of Gerontological Nursing. pp. 19-28.
Byers, Joan P. (1983, Sept/Oct). Sexuality and the Elderly. Geriatric Nursing. pp. 293-297.
Carter, Ann, M.D. (1997). Sexuality and Age: How Does Age Affect Sexuality? First Search: HealthRefCtr. Clinical Reference Systems Ltd, p. 2235.
Condor, Bob & Black, Lisa. (1998, May 3). Couples Adjusting to Life with Viagra. Chicago Tribune. Sec 1, p.1, col 5.
Drench, Meredith E. & Losee, Rita H. (1996, May/June). Sexuality and Sexual Capacities of Elderly People. Rehabilitation Nursing. vol. 21, n 3, pp. 118-123.
Nordheimer, Jon. (1998, May 10). Some Couples May Find Viagra a Home Wrecker. New York Times. sec 9, p.2, col 1.
Pfizer Labs, Inc. (1998, May). Viagra (sildenafil citrate) tablets. Drug Information Insert. Description, Clinical Pharmacology, Indications and Uses, Contraindications, Precautions, Adverse Reactions, Overdosage, Dosage and Administration, and How Supplied.
Richardson, James P. (1995). Sexuality in the Nursing Home Patient. American Family Physician. v 51, n 1, pp. 121 (4).
1-Semmens, P. James, M.D. (1997, Dec). Older Adults and Problems with Sexuality. First Search: HealthRefCtr. Clinical Reference Systems Ltd., p. 2153.
2-Semmens, P. James, M.D. (1997, Dec). Psychological and Social Problems of Midlife Sexuality. First Search: HealthRefCtr. Clinical Reference Systems Ltd, p. 2624.
Sokolowski, Jay. (1982, July/Aug). Sexual Behavior of the Aged. Gerontologic Review. vol. 5, pp. 214-215.
Wee, Eric, L. (1998, May 6). Viagra? Not Tonight, Dear. For Some Couples, the Anti-impotence Drug Has a Downside. Washington Post. Sec D, p. 1, col 3.
Weg, Ruth (1989, Sept/Oct). The Biological Facts: Myth Versus Reality. Geriatric Nursing. p. 305