Elderhood

by Louise Aronson

  Some have argued that because of gay male culture’s focus on a young, buff, and beautiful version of sexual attractiveness,26 aging may be particularly difficult for gay men, especially those who are estranged from family or lost many peers in the early years of AIDS. Some of this is supposition, as little research has been done on sexual attractiveness and activity of LGBTQ elders. A search of the literature on the topic yielded primarily articles about sexual identity and health-related sexual challenges in old age. We know even less about lesbian, trans, or gender-fluid old people, though we do know that as groups they are more marginalized and have poorer health, two situations not generally correlated with sexual appeal.

  Regardless of sexual identity, men are often said to have more options, and while that appears to be true, their romantic old age has its own disappointments. Men report surprise when their once effective charms aren’t even noticed or, worse, are considered cute or absurd. All they want is what they’ve always wanted. The sportswriter and essayist Roger Angell, in his nineties, put it this way27:

  More venery. More love; more closeness; more sex and romance. Bring it back, no matter what, no matter how old we are. This fervent cry of ours has been certified by Simone de Beauvoir and Alice Munro and Laurence Olivier and any number of remarried or recoupled ancient classmates of ours. Laurence Olivier? I’m thinking of what he says somewhere in an interview: “Inside, we’re all seventeen, with red lips.”

  Not all men feel that way. Some are done. They let their beards grow and change their clothes less often, joking that this is how they always would have lived but for social norms and the need to be appealing. Others struggle to unify their identity and appearance. A nurse twice told me the story of a gay men’s musical theater group he’s been going to since the 1970s. He said he loved it but always joked how, himself and a few others aside, the audience was full of old farts. Nearing seventy, it only recently occurred to him that he now fits right in.

  The psychological literature of old age attests that all these reactions are common. A person’s response to being demoted from sexual being to “old person,” a state commonly if mistakenly assumed to be asexual, depends a good deal on how much they still care about sex, their romantic aspirations and prospects, and the role of sexuality in their life to that point. As with everything old-age-related, responses vary, and the reactions of the not-old are telling. The wedding of a couple in their nineties or hundreds makes the national news, as if at that age people should no longer want romance or companionship, affection and communion. Donald Hall found he could no longer write poetry once his testosterone levels reached their nadir. Diana Athill notes that “about halfway through my seventies I stopped thinking of myself as a sexual being, and after a short period of shock at the fact, found it very restful. To be able to like, even to love, a man without wanting to go to bed with him turned out to be a new sort of freedom.”28

  Once, when I took care of two sisters, one in her late eighties, the other in her early nineties, the younger one told me the older one was still having sex with her husband and insisted that I speak to her about it. When the older sister arrived, I could tell from her averted eyes that she, too, had received the propriety lecture. A few questions established that she and her husband both enjoyed their couplings. I told her there was no medical or other reason I knew of for stopping, and she beamed.

  The opposite of sexy isn’t so much unattractive as invisible. The first time I noticed I could no longer be seen, I was at a park near my house. My dog sniffed a shrub’s damp leaves near a young woman’s feet. She spoke into her cell phone. “No,” she said as I stood a few feet away. “There’s totally no one here.”

  “Talk to me, not my daughter!”29 demanded an octogenarian after salespeople repeatedly directed their questions to her fifty-something-year-old daughter, even when her daughter repeatedly turned to her mother for the answers.

  In a trendy new restaurant before a famous author event in a large auditorium nearby, my mother began talking about the couples closely seated on either side of us. “Mom,” I said pointedly, giving her a look that was meant to signal that not everyone has hearing loss and the people whose dress and behavior she was commenting on were right beside us. “Don’t worry,” she answered. “I’m invisible.”

  It has been said that for straight white males, being seen and treated as old can be their first real experience of being on the downside of social assumptions and discrimination. In old age, they lose the sexiness of their former social power and stature. They describe becoming invisible, invoking experiences long familiar to people of color and women. Roger Angell tells of a dinner out with younger friends:

  There’s a pause, and I chime in with a couple of sentences. The others look at me politely, then resume the talk exactly at the point where they’ve just left it. What? Hello? Didn’t I just say something? Have I left the room? … (Women I know say that this began to happen to them when they passed fifty.) When I mention the phenomenon to anyone around my age, I get back nods and smiles. Yes, we’re invisible. Honored, respected, even loved, but not quite worth listening to anymore.

  Angell’s friends were not so young that one might imagine they didn’t know better. They were in their sixties. It’s often the almost or newly old who go to the greatest lengths to distance themselves from old age. Both tragic and ironic, they distinguish themselves from even older people by mimicking the way many younger people treat them.

  Donald Hall describes a similar experience: “A grandchild’s college roommate, encountered for the first time, pulls a chair to sit with her back directly in front of me, cutting me off from the family circle: I don’t exist.” Both Hall and Angell told these anecdotes to the world in high-circulation magazine essays that were sufficiently popular that they grew up to be parts of notable books. Putting aside the obvious rudeness and cruelty these men faced, their books provide evidence that both were not only compos mentis but witty and insightful (two traits I find quite sexy) at the time these incidents took place. In old age, even the brilliant, famous, and fairly unimpaired are ignored. The implications for the truly unsexy and invisible, those who can’t quite follow a conversation for reasons from hearing loss to dementia, are terrifying.

  Sexiness also matters in the world of health care, where the unofficial label for higher-caste diseases, patients, problems, and solutions is sexy. Heart disease is sexy. Cancer is sexy. All things procedural are sexy. Aging is not sexy. Since hearts and tumors are neither attractive nor desirable, the problem isn’t one of aesthetics. It’s one of value, both medical and social.

  Lots of “not sexy” ailments can accompany old age. People with incontinence, falls, arthritis, constipation, insomnia, and vision and hearing loss often give up jobs and treasured activities. They lose confidence, comfort, and eventually friends. Some fall prey to profiteers promoting unproven therapies. This downward spiral doesn’t affect just the afflicted individual; it affects us all, socially and economically, directly and indirectly. Fear and shame lead to inactivity and shrunken social circles, two of the strongest predictors of poor health and the need for expensive services.

  Imagine being incontinent. Your underpants are wet, cold, and itchy against your skin. You worry that you smell. You live in constant fear of accidents, the wetness showing through your clothes. You avoid events that last too long or without easy bathroom access. At some point, there’s an episode that leaves you so embarrassed and ashamed that you stop going out. Thirteen million Americans are incontinent,30 and half of noninstitutionalized people over age sixty-five report urinary leakage. Incontinence is among the top medical reasons preventing people from going out and leading to institutionalization—outcomes that adversely affect health and quality of life. Traditionally, doctors and nurses haven’t asked about incontinence31 the way they ask about other common symptoms, and patients haven’t brought it up. Many assume little can be done. In fact, often little is done because, like the general public, doctors and nurses
receive inadequate education about how to manage it.

  All geriatric problems have multiple effective treatments. But only some offer cures with the clean-cut outcome of cataract surgery, one of the sexier treatment options for an age-related disease. Yet the “less sexy” treatments often make life worth living. Imagine what might be possible if these conditions and management strategies were given the same respect as high blood pressure or athletic injuries and their treatments. Just as caste systems keep lower castes in a relentless cycle of poverty and drudgery, so does medicine’s sexiness hierarchy deprive millions of Americans of healthier, fully engaged lives.

  One year, I decide it’s time to stop wearing a bikini. The next year, I give up exercise shorts.

  I notice for the first time that most women my age and older do the same. A year or two later, I decide tank tops, too, have become unbecoming. I donate mine to a charity. Some friends tell me the problem is in my head; I’m fit and reasonably trim. I think of a colleague who, in her middle sixties and older, dressed in trendy clothes that would have looked cute on one of our medical students but on her often struck me as incongruous, maybe embarrassing. I reason that I didn’t wear at thirty-three what I wore at thirteen, so it makes sense that different clothing suits me better now as well.

  Since clothing is an expression of self, it’s only logical that a person’s clothes change over time, just as bodies and people do. At fifty, even the most gorgeous men acquire a certain jowliness. After menopause, even slim women develop at least a hint of “menopot.” By the eighth decade and beyond, most bodies shrink, hunch, bend. A flattering outfit from a few years earlier suddenly doesn’t fit or seem attractive. The Puritans had strict rules for old-age attire: “For old men to be gay and youthful in their apparel, or if aged women dress themselves like young girls, it exposeth them to reproach and contempt.” Translation: what looks trendy on a twenty-year-old body might differ from what looks fashionable on a sixty- or eighty-year-old body.

  But even here, at this juncture of sexiness and invisibility, fashion and function, there’s an interplay of culture and biology. In Women and Power, the classicist Mary Beard makes a convincing case for the origins of our present notions of male and female speech and power32 having originated in ancient Greece. Similarly, when it comes to old age and appropriateness, it seems my own beliefs, which previously struck me as pragmatic and thoughtful, have their origins in American Puritanism. Recognizing that raises an important question: Since bodily changes with age are natural and universal, couldn’t clothes differently manifest style and sex appeal across all age groups? Presumably, they can and, certainly, they should. It’s not only fair and kind, but a considerable business opportunity languishing unclaimed in the marketplaces of clothing and fashion.

  Over coffee, a young man who works at a large, familiar tech company tells me they are moving into the “aging space.” There’s money there, he says, and opportunity—in other words, it’s becoming sexy, at least to the higher-ups with their eyes on changing demographics and the corporate bottom line. Farther down the company food chain, however, the staff isn’t feeling the passion. Being assigned to the aging project is considered the worst assignment: Sad. Lame. A drag. A bummer. A punishment.

  My acquaintance confides that he only agreed to lead this project to get his foot in the door, but as he’s spoken to actual old people (something he’d never previously done), he realized two things. First, spouse-partner-friend caregivers are shocked that he’s using the words older adult to refer to them, not just the person they care for, though to his eyes they are “no question, old.” Second, he can’t get even his middle-aged colleagues to approach the aging project in the same way they approach all other projects: objectively. Instead, they tell him about their father or grandmother, going straight to stories of disaster and decline. In company brainstorming groups where discussions are usually based on facts, they ignore the research reports he has provided and instead exchange loss and debility anecdotes. He can’t get them to see that the experiences they are emphasizing may not be representative and that old age can be approached with the same open mind and intellectual rigor as every other topic.

  Geriatrics frequently elicits the same reaction. One of the most well-known and influential physicians in America has described my specialty as “difficult and unappealingly limited.”33 I’m biased, obviously, but how can a field devoted to caring for all medical conditions of all people in one of life’s three decades-long age groups be described as limited? It’s similarly worth considering why we hear a lot about surgical difficulty, but never that it lacks glamour. To me, all that cutting and rearranging is repetitive and dull—I cannot imagine spending my days that way—but I’m able to appreciate its value to patients and the world.

  In medicine, some specialties are tops, while others are bottoms. But here’s the rub: when we treat entire categories of people as less interesting and worthy, we devalue part of their humanity, and forfeit some of our own.

  DISILLUSIONMENT

  In the months leading up to my burnout, I experienced two types of problems, one physical, one psychological, and, in retrospect, intimately interrelated. Physically, I struggled to do basic things like see well enough to work on a computer or drive my car. I couldn’t walk without pain or exercise to relieve the stress of my lost functions and frustrations. Responses to these developments—mine and those of my supervisors—didn’t help. Like a good doctor, I soldiered on. Like a typical doctor, I didn’t consult a clinician other than the one in the mirror.

  When, pre-snap, I mentioned challenges at work, I was offered a large monitor and other workstation modifications that took over fifty hours and several months to find, understand, and manage, time I could ill afford to lose. Luckily, our proactive administrators, with understated kindness, helped me place orders for adaptive equipment. My doctor-bosses, by contrast, made mild noises of sympathy but, busy and overworked themselves, failed to make any of the changes that would have helped me work around my physical challenges. In medical culture, one doctor’s struggles are another’s inconvenience. Knowing that, I should have been more emphatic and explicit about my needs, and more empathetic and forgiving about theirs.

  But this was not my finest moment; I had no reserves from which to draw such a sensible and generous approach. Instead, I tuned out or quietly rebelled. If, for example, having mentioned again that I couldn’t see the tiny screen on which we were being shown the new charting task we clinic providers were required to do in the electronic medical record, and again having been ignored, I felt entirely justified in simply not doing it. This is not the wisest strategy for a person who wants to be a good doctor and decent colleague.

  We know the origins of the common usage of the term burnout. In the early 1970s the German American psychologist Herbert J. Freudenberger used it to describe work-related stress he saw in physicians. Freudenberger observed that medical practice changed some doctors from passionate idealists to depressive cynics who treated their patients with cold indifference. Investigating further, he found the disillusioned doctors all shared certain traits: a strong work ethic, high achievement, and a tendency to see their work as essential to their identity. Once burned out, they also shared symptoms including disturbed sleep, mood fluctuations, and difficulty concentrating. Long-term stress adversely affected their bodies and minds, keeping them on high alert, as if they continuously faced a lethal threat. Their combination of high work engagement and incessant strain led to a vicious cycle of self-neglect, value revision, changed behavior, challenged relationships, withdrawal, and inner emptiness.

  Increasingly, I had found myself easily startled and unable to recall simple words and statistics. I lay awake most nights between two and four in the morning, thoughts racing and heart percussing. I worried about my patients: Would S’s daughter show up? Had I done the right thing for H? Would M fall again? I also ran through long lists of all the things I hadn’t yet done and all the people who were making m
y life so unpleasant, then conjured up things I might have said or done and, finally, plausible escape routes: a broken hand that precluded typing, the sort of cancer that would get me off work for a good long time but wouldn’t kill me, a family crisis that required my particular presence. I’d drift into an exhausted sleep just before my alarm went off to a new day with a full inbox, a schedule that allowed no time for meaningful note writing, countless other competing tasks and responsibilities, and wholly inadequate time for actually doing those things that could legitimately earn the label patient care or felt meaningful.

  What I was seeing was happening everywhere and doctors were beginning to speak and write about it. In Omaha, Byers “Bud” Shaw, a transplant surgeon, stopped practicing when he found himself too anxious to leave his office,34 much less pick up a scalpel. In Boston, the internist Diane Shannon left medicine because of the constant tension35 between the sort of medicine she wanted to practice, “compassionate, safe, dependable, connected, and humane,” and a health delivery system that seemed to value and prioritize everything but those elements. An unnamed hospital-based doctor quoted on NPR said, “If I took the time to actually talk with my patients, which is what drew me to medicine in the first place, it meant I fell behind36 and then spent hours and hours at home in the evening doing the required data entry.” An outpatient-clinic doctor colleague of mine noted different but related pressures in his setting. Even if he finished his notes before heading home, he spent “2–3 hours every day/night on in-box stuff (e-mails and phone calls from patients, nurses, and pharmacists)—this is uncompensated, underappreciated work that we do on a daily basis and bleeds into our evenings and weekends. This work happens whether it is a clinic day or a non-clinic day. There is no escape and no relief.”37 A doctor’s interests and inclinations push one way, toward patients and care, and the system pushes the other, toward computers and tasks that are essential but not factored into our work schedules.