From Couplepause to Doublepause: Naming the Gap in Holistic Sexual Health Care for an Aging Group

Increasing life expectancy while maintaining quality of life is a central goal of modern society. According to the World Health Organization (WHO), sexual health is one of the indicators of quality of life [1]. However, aging presents complex challenges that demand attention to sexual health in later life. As we age, bodily functions decline, including the decline in sex hormone levels, known as menopause in women and andropause/late onset hypogonadism in men [2, 3]. Sex steroids are not only beneficial for sexual and reproductive function but also contribute to other organ functions. Therefore, the decline of sex hormones in old age also affects other organ functions such as heart, muscle, brain or psychological state [4]. This is noteworthy because age-related decrease in organ function can directly and indirectly impact sexual health.

On the other hand, age, psychological, and sociocultural changes also affect sexual relation [5]. Older adults in this era are the first to experience the sexual freedom brought about by the recent social movements. They are also in the unique position of experiencing the tension between the construction of sex for reproduction and sex as self-expression [6]. This makes aging a multidimensional experience. However, our understanding has often been limited to the biomedical perspective, which should not be the case.

Talking about sexual health is inherently relational and shared regardless of the population. However, in practice, health services still orient sexual problems as personal problems. In the aging group, a significant change in body function is accompanied by a “relatively” sedentary condition that significantly affects long-term sexual health. In addition, older individuals also tend to have older partners (the same age). Thus, “Couplepause” and its expanded concept, “Doublepause” offer alternative frameworks that shift attention from isolated biological decline to the interpersonal realities of aging intimacy [7].

The term couplepause was coined by Janini and Nappi (2018) [8] in the journal Sexual Medicine Review. In 2024, in the same journal, Janini and 4 other sexual experts extended the term couplepause to the term doublepause [7]. This paradigm shift encourages healthcare providers to address middle-aged group experiencing decreased sexual function. It encourages its wider use by not only sex therapists but also gynecologists, andrologists, endocrinologists, urologists, geriatricians, general practitioners, and others who have traditionally seen these patients separately [9].

The concepts in this terminology are not new or unfamiliar. The framing being offered by this term is a holistic and comprehensive frame in the management of sexual health, so that the management does not focus only in 1 viewpoint, but also multiple perspectives. Giraldi et al. (2024) [7] emphasize that the key to the use of this terminology refers to several values such as a focus that shifts to the needs of the couple rather than the individual. Facilitating the unmet needs of doctors and health workers who treat, focusing treatment on all aspects of change including each partner, handling therapy together with the partner as well as points of cooperation and multidisciplinary communication between fellow health care providers such as gynecologists/andrologists and other specialists is critically important [7].

This means that patient care will be more “couple-oriented” than “person-oriented”. This term emphasizes that when 1 partner experiences hormonal or psychological changes, the effects spill over into the relationship dynamics. Expanding this to a doublepause suggests that both partners are experiencing the same transition, although it may differ [10]. This includes physiological changes and evolving needs, identities, desires, and emotional roles [10]. Simply put, this terminology emphasizes that sexual issues are part of a couple’s shared experience, emphasizing multidisciplinary counseling [4].

This terminology will undoubtedly raise awareness in addressing sexual health concerns among older couples. Simple and catchy terminology will make it easier for health workers to remember the process of intervening with couples and then initiate sexual conversations with them [11]. Framing these experiences of sexual impairment as doublepause, provides space for empathy, negotiation, and mutual adjustment. This terminology also encourages us to frame aging intimacy not just as a problem to be fixed, but it becomes an evolving space to be navigated together [12, 13]. This terminology holds therapeutic value in clinical settings, helping couples articulate experiences that extend beyond sexual performance.

The “couplepause to doublepause” principle presents a new paradigm that addresses integrated sexual health issues. To be more holistic and not segmented between disciplines, this paradigm will undoubtedly open a new space in inclusive and multidisciplinary research. Hopefully, the holistic model inspired by this paradigm will advocate for diversity in representation, language, and lived experience. However, this concept requires critical evaluation in practice, such as the potential to oversimplify complex relational dynamics by assuming sameness or synchronicity in sexual experiences. Not all couples age together harmoniously. Some may face power imbalances, long-standing conflicts, or gender expectations that complicate the ideal joint transition [14, 15].

In addition, adaptations in different languages are a limitation. As the terminology originates from English, it may lack equivalent translations in other languages or cultural contexts, especially in communities where open discussion of sexuality at an older age is still considered taboo [16]. Therefore, its adoption must be accompanied by cultural sensitivity and empirical validation. Furthermore, when taken literally, this term’s usage can also signify several things, such as “a pause in the couple”. Therefore, in order to comprehend it, it must be appropriately altered [9].

Another risk of implementing the idea is the unintentional romanticization of couple life. While many older adults are in committed partnerships, others may be single, divorced, widowed, or in the dating phase [17]. The term “doublepause” inherently focuses on the couple, which may unintentionally marginalize the solo sexual experiences or sexual health needs of those outside of long-term partnerships. To determine how well this paradigm works for treating sexual health in older populations, more study is required. Therefore, even though the term is legitimate, it should be used flexibly and with consideration for its limitations.

References

[1] WHO. The World Health Organization Quality of Life (WHOQOL). 2012. Available at: https://www.who.int/publications/i/item/WHO-HIS-HSI-Rev.2012.03 (Accessed: 16 May 2025).

[2] Jakiel G, Makara-Studzińska M, Ciebiera M, Słabuszewska-Jóźwiak A. Andropause - state of the art 2015 and review of selected aspects. Przeglad Menopauzalny = Menopause Review. 2015; 14: 1–6. https://doi.org/10.5114/pm.2015.49998.

[3] Lunenfeld B, Mskhalaya G, Zitzmann M, Arver S, Kalinchenko S, Tishova Y, et al. Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. The Aging Male: the Official Journal of the International Society for the Study of the Aging Male. 2015; 18: 5–15. https://doi.org/10.3109/13685538.2015.1004049.

[4] Sanchez-Borrego R, Molero F, Castaño R, Castelo-Branco C, Honrado M, Jurado AR, et al. Spanish consensus on sexual health in men and women over 50. Maturitas. 2014; 78: 138–145. https://doi.org/10.1016/j.maturitas.2014.02.020.

[5] Ricoy-Cano AJ, Obrero-Gaitán E, Caravaca-Sánchez F, Fuente-Robles YMDL. Factors Conditioning Sexual Behavior in Older Adults: A Systematic Review of Qualitative Studies. Journal of Clinical Medicine. 2020; 9: 1716. https://doi.org/10.3390/jcm9061716.

[6] Towler LB, Graham CA, Bishop FL, Hinchliff S. Sex and Relationships in Later Life: Older Adults’ Experiences and Perceptions of Sexual Changes. Journal of Sex Research. 2023; 60: 1318–1331. https://doi.org/10.1080/00224499.2022.2093322.

[7] Giraldi A, Nappi RE, Palacios S, Reisman Y, Jannini EA. From couplepause to doublepause: the impact of midlife physical, psychological, and social changes on the sexual life of aging couples. Sexual Medicine Reviews. 2024; 12: 346–354. https://doi.org/10.1093/sxmrev/qeae016.

[8] Jannini EA, Nappi RE. Couplepause: A New Paradigm in Treating Sexual Dysfunction During Menopause and Andropause. Sexual Medicine Reviews. 2018; 6: 384–395. https://doi.org/10.1016/j.sxmr.2017.11.002.

[9] Rozenberg S, Nappi RE, Schaudig K, Jannini EA, Giraldi AGE. Couplepause: deconstructing sick menopause and andropause during midlife. The Journal of Sexual Medicine. 2023; 20: 1270–1273. https://doi.org/10.1093/jsxmed/qdad113.

[10] Limoncin E, Mollaioli D, Sansone A, Colonnello E, Ciocca G, Balercia G, et al. Dyadic Satisfaction and Shared Affectivity Are Associated with Psycho-Sexual Functioning in Elderly Men and Women. Sexes. 2022; 3: 68–77. https://doi.org/10.3390/sexes3010006.

[11] Ezhova I, Savidge L, Bonnett C, Cassidy J, Okwuokei A, Dickinson T. Barriers to older adults seeking sexual health advice and treatment: A scoping review. International Journal of Nursing Studies. 2020; 107: 103566. https://doi.org/10.1016/j.ijnurstu.2020.103566.

[12] Gott M, Hinchliff S. How important is sex in later life? The views of older people. Social Science & Medicine (1982). 2003; 56: 1617–1628. https://doi.org/10.1016/s0277-9536(02)00180-6.

[13] Flynn KE, Lin L, Bruner DW, Cyranowski JM, Hahn EA, Jeffery DD, et al. Sexual Satisfaction and the Importance of Sexual Health to Quality of Life Throughout the Life Course of U.S. Adults. The Journal of Sexual Medicine. 2016; 13: 1642–1650. https://doi.org/10.1016/j.jsxm.2016.08.011.

[14] Lindau ST, Gavrilova N. Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing. BMJ (Clinical Research Ed.). 2010; 340: c810. https://doi.org/10.1136/bmj.c810.

[15] Oliffe JL, Rasmussen B, Bottorff JL, Kelly MT, Galdas PM, Phinney A, et al. Masculinities, work, and retirement among older men who experience depression. Qualitative Health Research. 2013; 23: 1626–1637. https://doi.org/10.1177/1049732313509408.

[16] Rebec D, Karnjuš I, Ličen S, Babnik K. Breaking Down Taboos Concerning Sexuality among the Elderly. In Polona Mivšek A (ed.) Sexology in Midwifery (pp. 189–207). InTechOpen: London. 2015. https://doi.org/10.5772/59302.

[17] Wright MR, Brown SL. Psychological Well-Being among Older Adults: The Role of Partnership Status. Journal of Marriage and the Family. 2017; 79: 833–849. https://doi.org/10.1111/jomf.12375.