Social isolation may have serious health consequences; urologists can help.
Although loneliness is not a diagnosable illness, it is a common and misunderstood mental health problem for men and women of all ages. This is especially true for men over the age of 60 years who may view loneliness as a shameful secret. This applies to married as well as divorced or widowed men.
Our cultural stereotype of older men offers a sharp contrast to the emotional reality of loneliness. We focus on “socially desirable” messages such as retired men playing golf, fishing, or acting as the patriarch of family events. However, for many older men loneliness is a chronic problem, and for a large number it is a recent (since retirement) experience. Loneliness is multi-causal and multi-dimensional with large individual, relational, cultural, and value differences.
To provide perspective, it is important to note that the majority of men do thrive with aging and retirement. However, a significant number-as many as 30%-“crash and burn.” This involves high levels of anxiety and depression, alcohol or drug abuse, and greater risk of suicide attempts and completion (McCarthy B, McCarthy E. “Therapy with Men after Sixty.” New York: Routledge; 2014). One of the best predictors of major problems is when a man stops being sexual. This does not just mean stopping intercourse, but avoiding any type of sensual or sexual touch, including affectionate touch.
When a spouse dies, a majority of men eventually remarry and reestablish a new social support system with their new spouse and her family. In terms of quality friendships, men often report more acquaintances while women report more quality friendships and closer relationships with older and younger family members. For too many men, their only close relationship is with their spouse.
Health consequences of loneliness
There are a number of potential physical and mental health consequences of loneliness. The lonely man does not feel accountable to anyone so he may avoid making medical appointments and following through with recommended diagnostic tests (eg, colon cancer screening).
A particularly powerful example is the man who is told he needs a biopsy to rule out prostate cancer. He puts off scheduling the biopsy because he is afraid of the potential outcome. Embarrassed that he did not follow through on making an appointment, he cancels it altogether. Five years later, the man is admitted to the hospital with stage 4 prostate cancer with a poor prognosis.
Lonely men usually do not engage in preventive health care. Seldom do they make yearly appointments with their primary care physician. In addition, poor behavioral health habits including poor sleep patterns, lack of exercise, poor eating habits, smoking, and alcohol or drug abuse are common and subvert health. Finally, the lonely man is unlikely to follow a disciplined regimen of taking prescribed medications.
This pattern of neglect and unhealthy behaviors increases the risk of mental health problems, while the lack of social support reduces the chance that the man will seek assistance. Over time the problems become chronic and severe. Health cannot be treated with “benign neglect.”
Next:Role of the urologistRole of the urologist
Should loneliness be a concern for the urologist? The traditional narrow approach to urology has been that of a specialist focused on assessing and treating a specific medical problem-a “plumber” who fixes a man’s broken parts. The biopsychosocial model for assessment and treatment of older men recommends that the urologist be an “ask-able” doctor who is available to discuss a range of biomedical, psychological, and relational/social concerns, including loneliness (table 1). Rather than asking “yes/no” questions, the urologist is encouraged to ask open-ended questions, giving the patient an opportunity to tell his story and disclose concerns (table 2).
It is difficult, though, for men to share their vulnerabilities as many try to emulate the “strong man” cultural stereotype. In reality, even the most psychologically and physically healthy men have vulnerabilities. Too often, a man has “contingent self-esteem,” believing that if others knew his problems they would not accept him or would feel sorry for him. The reality of men’s lives is that by age 60, everyone has had at least one experience (and usually many more) where they have felt guilt, regret, sadness, or loneliness. This is a normal part of the human condition, yet many men view it as a “shameful secret.”
Rather than assuming that loneliness is better treated by the primary care physician or a mental health professional, be an “ask-able,” caring urologist. At minimum, this means listening and affirming that loneliness is a common problem for a man after 60. Your empathy and respect can help motivate him to break the cycle of isolation and shame by normalizing the experience. You can serve as a gatekeeper and encourage him to accept a referral for specialized treatment with a psychologist, marriage therapist, minister, or other helping professional.
In some cases, you can assist directly with the loneliness problem by understanding its context and making specific suggestions. For example, you could suggest becoming involved as a volunteer in a community or religious organization, assisting with a Boy Scout group, teaching English as a second language, joining a gym or walking group, or volunteering for a social or political cause. This moves beyond simply telling a man to make new friends, which can be counter-therapeutic. Encouraging his involvement in new groups and activities is more likely to be helpful.
Specific suggestions can also be helpful for men dealing with marriage difficulties and alienation or contention in relationships, such as with a sibling or adult child. Just telling a man to restore these relationships will likely set him up for failure. A more helpful route is to bring up one specific activity that could facilitate re-engagement. It could be small, like going to a sporting event, or more significant like taking a weekend trip.
A urologist who engages with the patient demonstrates a personal interest in his quality of life and facilitates avenues for him to break the cycle of loneliness. In addition, ask the patient to report afterward whether the suggestion or referral was useful. Add this to your notes and check in with him at his next appointment.
Next:Older men and sexualityOlder men and sexuality
Most men learn to be sexual in an autonomous manner: they experience desire, erection, intercourse, and orgasm without needing anything from their partner. A core learning is that sexual function is predictable and in a man’s control, which does not serve him well as a 60-year-old. With aging, his vascular, neurologic, and hormonal systems are less efficient so that psychological, relational, and especially psychosexual skill factors become more important.
The good news is that there is solid scientific evidence that men can be sexual in their 60s, 70s, and 80s (N Engl J Med 2007; 357:762-74). The bad news is that when couples stop being sexual, it is usually the man’s choice because he has lost confidence with erections and intercourse. He falls into the cycle of anticipatory anxiety, intercourse as an individual pass-fail performance test, frustration, embarrassment, and eventually avoidance.
Both urologists and the public often believe that the answer to erectile dysfunction is oral medication as a stand-alone intervention, with penile injections as the back-up treatment. Sex therapists and sophisticated urologists support the biopsychosocial model of assessment and treatment, which includes the partner. The most important factor is to replace the individual intercourse pass-fail performance model with the Good Enough Sex (GES) couple approach of sharing pleasure (Metz M, McCarthy B. “Coping with Erectile Dysfunction.” Oakland, CA: New Harbinger; 2004). In addition, sexuality in this approach is viewed as a couple process, meaning that a man views his partner as his intimate and erotic friend.
The key is acceptance that sexuality is more flexible with age; this is true whether he uses erectile dysfunction medications or not. In rebuilding erectile comfort and confidence, positive, realistic GES expectations are crucial. Perhaps 85% of sexual encounters will flow from comfort to pleasure, arousal, erotic flow, intercourse, and orgasm. When sex does not flow, rather than panic or apologize, the couple seamlessly transitions to either a sensual or erotic scenario. Although intercourse is highly valued, the couple does not need intercourse to enjoy desire, pleasure, eroticism, and satisfaction (Metz M, Epstein N, McCarthy B. “Cognitive-Behavioral Therapy for Sexual Dysfunction.” New York: Routledge; 2017).
This is a new way of thought for many men (and many urologists) but is key for them to continue to be sexual in them 60s, 70s, and 80s. Traditional men give up on sex because of performance fears. “Wise” men embrace GES and remain sexually active, which involves affectionate, sensual, playful, and erotic touch in addition to intercourse. The wise man turns toward his partner whether the sexual experience was wonderful, good, or dysfunctional. Lonely men avoid partner sex because they fear failure.
The decision to stop being sexual is a self-defeating one. It reinforces isolation, alienation, and loneliness. The man feels he cannot perform like a “real man” and that he is alone in his failure even with using an erectile dysfunction medication. Based on the over-promising ads, almost all men fail.
The major mistake men make is rushing to intercourse as soon as they become erect for fear of losing their erection. A healthy strategy is not to transition to intercourse until both partners are in erotic flow (high levels of subjective and objective arousal). Sex with aging is an intimate sexual team experience. Healthy couple sexuality is an antidote to loneliness. As a doctor, you will have more success when you acknowledge the importance of the biopsychosocial model, rather than solely writing a prescription.
Acceptance and change
It is crucial that the urologist accept that loneliness is a common problem for men over 60 and that it is multi-causal and multi-dimensional. It need not be a shameful secret, and denial or avoidance only give loneliness more power than it deserves. The urologist can be a gatekeeper and make referrals. In many cases, the urologist can directly address loneliness by helping the patient accept its seriousness in impacting physical and mental health and making suggestions to break the cycle. Sexuality is an excellent example of using all of a man’s biopsychosocial resources, especially by enlisting a partner as his intimate and erotic ally.
Barry McCarthy, PhD
Tamara Oppliger, MA
Dr. McCarthy is professor of psychology at American University in Washington, a diplomate in clinical psychology, a certified sex therapist, and a certified couple therapist. Ms. Oppliger is a PhD student in clinical psychology at American University.
Section Editor Steven A. Kaplan, MD, is professor of urology, Icahn School of Medicine at Mount Sinai, New York.
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