Sex and Aging: Perspectives of Older Adult Women with Experience of Incarceration

Abstract

To explore perspectives on sexuality, sexual health, and sexual health care of older adult women with a history of criminal legal system involvement, we conducted phone interviews with women aged 50 years or older who were living in the community but had a history of jail and/or prison incarceration. Interview questions and initial analysis were guided by the sexual health framework for public health and Mitchell’s sexual wellness model. Data analysis followed a framework method. Nine women, aged 53–66, participated in phone interviews between December 2020 and December 2021. Slightly over half the participants were Black; none were Hispanic. Most were single. We formulated a sex-in-aging (SAGE) framework comprising three categories and two overarching themes. Women with a history of criminal-legal system involvement have heterogeneous views on sex and sexual health and describe a range of desire and sexual activity as they age, including shifting ideas about what they expect from partners, how they keep themselves safe in sexual and intimate relationships, and how life circumstances that are often associated with criminal legal system involvement (substance use, trauma) impact their interest in sex as they age. The SAGE framework integrates these categories and themes and offers a starting point for further research and intervention development.

The number of people in the United States who are criminal-legal system involved (i.e., jail or prison incarceration or custodial arrangements of probation or parole) on any given day is astronomical, far outpacing any other country in the world, both by the numbers and by rate (Walmsley, 2020). In the past decade, while the rate of incarceration of young men fell, rates for older adults and women have continued to grow (McKillop & Boucher, 2018). The most recent Bureau of Justice Statistics report to focus on the incarceration of older adults (age 55 and older) was published in 2016. That report calculated the growth rate of older adult representation in prisons at 400% between 1993 and 2013 (Carson & Sabol, 2016). In 2020, about 7.3% of people incarcerated in U.S. jails were over age 55, and about one-fifth over age 45 (Minton & Zeng, 2021). U.S. state and federal prison data from 2020 indicated 14% (~165,000 persons) in state and federal prisons were age 55 or older (Carson, 2021), with a full third (~380,000) age 45 or older. Women, too, have followed a trend counter to overall rates. For women of all ages, the incarceration rate increased 475% between 1980 and 2020 (Sawyer, 2018). Women number about 10–12% of incarcerated populations overall and about 9% of the group over 55, roughly 40,000 in number (Sawyer, 2018). Women also make up about 20% of the community supervised population (parole and probation), approximately 600,000 (Kaeble, 2021). Importantly, involvement in the criminal legal system is often repeated over the lifecourse, with reincarceration rates reaching 35% within in one year and 76% in nine years for women released from state prisons (Alper et al., 2018). The serial quality of incarceration reflects the fact that many of the forces that move people along pathways to criminal-legal system (CLS) involvement are themselves deep-rooted, systemic, and persistent (Kelly et al., 2014; Latham-Mintus et al., 2022).

Researchers have documented links between women’s criminal-legal system involvement and health, including premature mortality, that transcend the type (i.e., jail versus prison) of CLS involvement and to some extent the duration of CLS involvement as well (Binswanger et al., 2007; Massoglia et al., 2014; Massoglia & Remster, 2019). Many health risks that affect women follow from social determinants and life circumstances also associated—often bi-directionally—with CLS involvement: lack of stable housing, persistent poverty, untreated mental illness, substance abuse, and trauma related to racism or violence (Holtfreter et al., 2022; Kelly et al., 2014). For women with a history of CLS involvement, such factors may accelerate aging, leading to related health changes 10–15 years earlier than women without that history (Greene et al., 2018; Merkt et al., 2020). The very event of incarceration, even if brief, should not be overlooked since the unsanitary, overcrowded conditions; poor quality air and food; and limited opportunities for physical activity and cognitive stimulation in most carceral settings may on their own amplify, precipitate, or accelerate health challenges in middle and older adult women. Aging-related health challenges include chronic respiratory, cardiovascular, metabolic, and neurodegenerative diseases and conditions such as Parkinson’s and Alzheimer’s and other dementias (Ofori-Asenso et al., 2019). Aging may bring nutrition deficiencies linked to diet and/or oral health; impairment of vision, hearing, and balance, leading to increased risk of injury; chronic pain associated with arthritis; and increased social isolation and mental illness, especially depression. The CLS is poorly equipped to meet the needs of aging people of any sex and women more so than men due to their comparatively low numbers (Golembeski et al., 2020; McKillop & Boucher, 2018; Wennerstrom et al., 2022). Nor do older people with CLS involvement who live in the community fare much better, since determinants that are associated with incarceration are rarely resolved by incarceration (Metzger et al., 2018).

Much of what we know about the health and health services needs of women who are involved with the CLS applies to women before midlife or is cobbled together from studies that include older women in their analysis but are focused elsewhere (Emerson et al., 2022). Research specifically to document aging-related health and health services needs of older adult women whose lives have been disrupted by incarceration is rare (Barry et al., 2019; Emerson et al., 2022). In one exception, Latham-Mintus et al. (2022) analyzed data from the national, longitudinal Health and Retirement Survey to compare health indicators in community-dwelling women over age 50 who reported former incarceration with age-matched women who reported no history of incarceration. The work found multiple disparities and used an intersectional approach to highlight how accumulated stress of racism and discrimination may be compounded with incarceration to impact older women’s health. Aside from a small body of work to address specifically how menopause is managed in prisons (Jaffe et al., 2022; Jaffe et al., 2021), there has been virtually no attempt to understand how adult women with CLS involvement perceive and experience their sexuality and manage sexual health as they age. In this study, our purpose was to describe what we learned in interviews with women age 50 and older about their perspectives and experiences related to sex, sexual health, and sexual health care and to propose a tentative conceptual model for women’s sex and aging in a context of criminal-legal system involvement to guide future research and intervention.

Literature Review

Sexual health is considered a part of overall health across the life course by both the Centers for Disease Control and Prevention (n. d.) and the World Health Organization (n. d.). Both define sexual health from a biopsychosocial perspective that encompasses physical, mental, and social domains. Omitting the sexual component from health considerations of women as they age can mean missing important health education, prevention, and mitigation opportunities, including prevention of sexually transmitted diseases (STDs) like HIV and hepatitis C, detection and treatment of cancers of the reproductive system, and prevention or detection of sexual violence and abuse.

The sexual health model also points to women’s need for positive sexual intimacy, connection, and self-expression as they age. We know that sexual activity often declines in later life, but evidence indicates that many women remain sexually interested and active throughout the life span, finding pleasure and connection through sexual self-expression as they age (Bergeron et al., 2017; Kolodziejczak et al., 2019; Schick et al., 2010). In population-based research with older adults (ages 57–85), positive sexual experiences have correlated inversely with poor mental health, unhappiness, and psychological distress (Zhang & Liu, 2020). Importantly, older women also experience continuing risk of disease, injury, and death related to their sexuality. Rates of STDs have increased among older adults in recent years (Centers for Disease Control and Prevention, 2019), and STD testing rates are low. One national surveillance study indicated that nearly 70% of sexually active women aged 50 years and older with at least one risk factor did not receive STD testing in the previous year, and only 25–28% used condoms during vaginal intercourse (Schick et al., 2010). In a nationally representative study with U.S. adults aged 50–92 (n = 405), researchers compared actual sexual risk (multiple behaviors) with perceived susceptibility to STDs and found almost half (48.1%) the sample underestimated their sexual risk for STDs (Syme et al., 2017). Older women may need reinforcement of knowledge about the continuing relevance of condoms and additional support in building self-efficacy to insist on their use (Fileborn et al., 2018; Sinković & Towler, 2018).

Advancing age also does not preclude risk of rape, sexual assault, or sexual intimidation, which can include both intimate partner and stranger violence (Bows, 2018; Fileborn, 2017). Finally, although older women benefit from discussion with health care providers about how to stay safe and find pleasure sexually as they age, evidence suggests that only about a quarter of women talk to their providers about sex after turning 50 (Bergeron et al., 2017), and for those with mild cognitive impairment, the likelihood decreases (Lindau et al., 2018). Silence (of patients or providers) about sexual health can mean failure to address physical changes that result in pain during intercourse and shifts in sexual desire that may require adjustments in intimate relationships (Kingsberg et al., 2019)

Older adult women with a history of incarceration are likely to share many of the sexual health attitudes, experiences, and needs of other older women, but there is good reason to suspect that their needs and perspectives may also differ. For many women with CLS involvement, incarceration and probation happen not once but repeatedly, and the results can be pervasive, affecting women’s family life, employment, and health (Alper et al., 2018; Massoglia & Pridemore, 2015; Sawyer, 2019). As the gendered or feminist pathways model to crime explains, women’s CLS involvement is linked to certain life circumstances (DeHart, 2014; Holtfreter et al., 2022). These pathway determinants include long-term conditions of poverty and homelessness; mental illness; sexual exploitation and/or the exchange of sex for food, money, housing, and other resources; chronic trauma from abuse and interpersonal violence; and use of substances to cope with trauma (Gehring, 2016; Lambdin et al., 2018; Noska et al., 2016). Any of these factors can have bearing on sexuality and sexual health through patterns of disrupted or unhealthy relationships, insecure access to health care, and exposure to disease and violence (Kelly et al., 2014; Ramaswamy & Kelly, 2015).

Guiding Conceptual Models for Sexual Health

Research that focuses on the sexual health perspectives and experiences of older adult women with a history of CLS involvement is almost non-existent. Our purpose was thus exploratory: to explore with women age 50 years or older, who have a history of CLS involvement, their perspectives and experiences related to aging and sex. The Sex in Aging (SAGE) study was informed by the sexual health framework (Ivankovich et al., 2013) and Mitchell’s (2021) sexual wellness model. We sought to learn how sexuality and sexual health figured into the views of health and wellbeing of women with CLS involvement over time and how the women saw the role of intimacy evolving (or not) as they aged.

Method

Study Design

The study design was qualitative descriptive with one-on-one interviews. We used a framework method that combined inductive and deductive steps (Gale et al., 2013)

Sampling Strategy

Women were eligible for the SAGE study if they were 50 years or older; had any history of jail or prison incarceration; and were able to read, speak, and understand spoken English. Our study plan was to exclude individuals who were currently incarcerated or in a court-ordered residential program, though none were excluded on this basis. The women’s current incarceration or custody status did not bear directly on our research question, and we were mindful of the pandemic and the additional resources and time that recruitment of institutionalized participants might entail. Community-dwelling women with a history of incarceration were recruited by several methods. Most were referred to us (i.e., our information was provided to them) through their participation in the Tri-City Cervical Cancer Prevention Study with Women in the Justice System an ongoing study with adult women (age 18+) who have CLS involvement. Tri-City compares the navigation of services for cervical cancer prevention and other health by women in three cities that have diverse health policy, funding, and resource availability: Birmingham, Alabama; Kansas City, Kansas/Missouri; and Oakland, California (Salyer et al., 2021). We also posted social media advertisements in a private Facebook group for women who have CLS involvement, and we encouraged women who completed interviews with us to refer acquaintances by passing along our contact information. All interviews were conducted by the first author, concurrent with recruitment and analysis, between December 2020 and December 2021.

Fourteen women voluntarily contacted us. We completed interviews with eight of the 12 women who learned of us directly from Tri-City. One woman responded to our posting on the private Facebook group and completed an interview. One woman was referred to us through snowball sampling but did not complete an interview. In five cases, participants contacted the first author, gave consent, and scheduled an interview but then could not be reached. We do not know why consented participants did not interview, though in one case in which a woman screened and scheduled an interview and then was not reachable, we learned later she had lost her housing and her phone service.

Data Collection

The semi-structured SAGE interview guide included 12 open-ended questions exploring women’s perspectives and experiences over time related to intimate and romantic partnerships; physical desire and sexual behavior; reproductive and sexual health and sexual health care; sexual health experiences related to substance use; and experiences during incarceration related to sexual health care (Supplemental File 1). A brief demographic questionnaire was also administered. The first author, a PhD-prepared nurse researcher with previous experience using trauma-informed interviewing techniques with women during and after incarceration, screened, consented, and interviewed participants. Screening took place with the first author during an initial phone call, after which the second author emailed a copy of the consent to volunteers and scheduled the interviews. The first author revisited and summarized the consent prior to each interview, highlighting sections on study purpose; confidentiality and privacy, including the use of pseudonyms in research reports; and whom to contact if the participant had concerns or experienced difficulty following an interview. During this review, the first author solicited and answered questions.

In keeping with the pathways model and research indicating that women with CLS involvement experience trauma at disproportionate rates (Karlsson & Zielinski, 2020), the first author took steps to support women’s feelings of safety and control during the interviews (Alessi & Kahn, 2023). Questions were open-ended to allow women to approach a topic in her own way. The first author offered choices about recording and when to start and stop interviews. In two instances, women chose to have someone else present during the interview (one woman’s mother and another’s partner). The first author listened for cues that participants might feel uncomfortable with a line of questioning and was ready to check in, redirect, or pause the interview if she sensed women were struggling (Alessi & Kahn, 2023). We also offered women contact information for the first author as part of the consent if they needed to talk after the interview. All interviews were conducted by phone and audio recorded on a handheld device. Individual names, place names, and other identifying details were omitted in field notes and removed during transcription, and the authors assigned pseudonyms. We thanked the women who interviewed with a $25 gift card for participating.

Data Analysis

Data analysis followed a 6-step framework method (Gale et al., 2013). Transcription (Step 1) and reading and rereading to build familiarization (Step 2) were followed by independent coding and memoing (Step 3) of the transcripts by the first and second authors. Coding was guided by the sexual health framework for public health (Ivankovich et al., 2013) and Mitchell et al.’s (2021) sexual wellness model. Authors 1–3 then consolidated the most prominent codes into a smaller set of categories in Step 4 to formulate the analytic framework. We applied the main categories in analysis of the remaining transcripts (Step 5), further revising the framework as led by our evolving sense of the data. Finally, representative passages from the transcripts were charted for each category, the findings synthesized, and a model developed (Step 6). The framework method provided us with an efficient, replicable, step-wise structure for analysis in which we could move hermeneutically, first, between individual interview transcripts and field notes and the interviews as a group; and, second, between inductive processes of reading, open coding, and analytic memoing and deductive processes of framework fitting and revision.

Human Participant Protections

The SAGE study was reviewed and approved by the University of Kansas Medical Center Institutional Review Board (Approval #281226). All participants provided informed consent prior to interviewing. To safeguard the women’s confidentiality, the interview recordings, field notes, and other data were stored in REDCap on a university encrypted server, separate from identifying information. De-identified transcripts were read and coded in Dedoose.

Results

Participant Characteristics

The nine women we interviewed were 53 to 66 years of age. About half the women identified as Black and half White. None of the women identified themselves as Hispanic. The women were mostly single and reported various employment statuses. All had some form of government subsidized health care coverage, either Medicaid, Medicare, or disability income benefits through the Social Security Administration (Table 1).

Table 1.

Participant Characteristics

Name	Age	Race	Relationship Status	Employed	Income Assistance	Medicare/Medicaid Coverage
Jeri	56	Black	S		√	√
Irena	52	White	S	√
Teniesha	53	White	S
Allyson	55	White	S		√	√
Brandi	57	Black	S		√	√
Candice	66	Black	CR		√	√
Nancy	60	Black	S			√
Stephanie	52	White	CR	√
Maria	54	Black	S		√	√

Note: S = single; CR = committed relationship

Categories and Themes

We initially proposed six framework categories based on the sexual health framework and the sexual wellness model (Ivankovich et al., 2013; Mitchell et al., 2021). After the first four interviews, these were reduced to three categories and two overarching themes (Table 2). In each framework category and theme, we organized repeated and unique subtopics.

Table 2.

Sex in Aging Framework: Categories, Themes, Subtopics, and Examples

Category	Subtopics	Examples
Sexual & Reproductive Health & Health Care	• Attitudes, behaviors, about sexual health; sexual health care; and sexual safety	“No, I wouldn’t feel like I need that much protection, like I did when I was younger and having unprotected sex and having random sex, and sex with people I didn’t even know. So now, when I’m older, I would never put myself in that situation. I would still protect myself to a certain [extent], you know. I would probably be like, ‘Want to go to the doctor and both of us get checked?” (Teneisha, age 53)
		“I forgot to mark my last period. I can’t remember if it was February or May of last year since I’ve had my last period. So, I think I’m still menopausal. And I mean it’s been okay for me so far, like I get real hot from time to time. But the women I know that get the hot flashes and stuff, theirs is way different, way more intense than mine. So, I’m scared. I’m praying that mine just aren’t going to be that bad. […] I talked to my doctor at one point, finding out about hormone therapy in case it does get bad. He said that’s a last resort because they cost so much, they have so many other side effects. I don’t know. I just pray that I don’t have a really bad menopause.” (Stephanie, age 52)
Sexual Desire & Sexual Activity	• Frequency, quality, and nature of sexual desire and sexual activity	Yes, I do [desire sex]! Yeah, when it comes to that, it’s crazy to me. I was going to set up an appointment with psych. I didn’t think it was normal. Everyone that I come into contact with this, femalewise, they say it’s very normal, because [they] feel the same way. It’s really normal from what all my lady friends are telling me. (Candice, age 66)
		“I’m sorry, I don’t experience sexual pleasure. I don’t even know what happened. I don’t even trip off of it. It never even run across my mind or nothing. No, I don’t masturbate or nothing. I don’t get horny or nothing. I don’t know what’s wrong. I just asked my mom, thinking of this, I asked my mom what’s wrong. Cause I don’t even get the urge to have sex. Maybe it’s because I don’t have a partner.” (Maria, age 54)
Sexual Wellness & Positive Intimacy	• Reals and ideals of partners and relationships; intimate communication and comfort; self-determin-ation; self-esteem	“[B]ack then I really wasn’t searching, you know. I was trying to find me. I had to find me first before I could branch out to something else. Now that I’m older, I have exactly what I, just think it would be, you know? And I’m so comfortable and relaxed and just at one with myself. I’m at one with him. There ain’t no place better.” (Candice, age 66)
		“You know, it doesn’t have to be an all-the-time thing. Somebody to be comfortable with, you know. I don’t know if I really want somebody to be around all the time or not. So, yeah, a companion that is honest and easy-going. It gets lonely being single, but I have always been a kind of loner anyways. I like not having to answer to anybody, to do what I want when I want. But I mean it would ease the loneliness I feel.” (Allyson, age 55)
Overarching Themes
Influence of Life Experiences	• Life events and circumstances bearing on sex and intimacy	“Well, my last 3 relationships, I have 4 kids and 3 baby daddies, and they were all horrible, violent, abusive. So it would have to be a really nice guy that cared about financial, feelings, security, and safety. They would have to love children. My grandchildren are like my life, so family-orientated.” (Teneisha, age 53)
		“You know, I don’t have a desire cause I’m going through menopause. I don’t even want a man touching me. You know I really just don’t want a man touching me. Just gives me a really sickly feeling right now because I’m going through menopause. I don’t even like to be touched period. […] Dealing with sex for so long in my life, I don’t even think about sex. Because I dealt with it for so long. That was my occupation. That was how I fed myself. How I clothed myself.” (Brandi, age 57)
		“I think it’s just a block. I don’t, I mean I don’t [desire sex]. I had sex because being out there, trying to get drugs or money for drugs. But now it feels good just to be me. And if I don’t want to, I don’t have to. And [sex] never was a thrilling thing that we did. It was just something to do to supply my drug addiction. Do you understand that?” (Nancy, age 60)
Growing Older	• What women value about aging and perspective-taking on sex and intimacy	“I love to talk with the young girls, give them some experience and strength so they might ‘get it’ now instead of bouncing in and out like I did for so many years.” (Stephanie, age 52)

Sexual and Reproductive Health and Health Care

The women in the SAGE study were over age 50, which is within the range that experts consider “older adult” for persons with CLS involvement (Greene et al., 2018). The sexual and reproductive health concerns they shared formed the first category, sexual and reproductive health and health care. Key subtopics included menopausal transition, prevention of STDs, and avoidance of violence.

Menopausal Transition.

SAGE participants described experiences that spanned the menopausal transition. Of the seven who mentioned transition, five women were in menopause (i.e., had full hysterectomy or no period for 12 months). Five of the women described current or past perimenopausal symptoms, and two noted that they had no symptoms so far. The women who described symptoms referred to irregular periods, heavy bleeding, hot flashes, mood swings, difficulty sleeping, pain and tightness during sex, lack of desire for sex, and vaginal dryness. None specified treatment, but several of the women said they spoke with a provider about menopause or planned to do so. Nancy (age 60) and Stephanie (age 52) consulted providers about menopausal symptoms and found the visits helpful, though neither was recommended treatment; one had been advised against medical treatment due to cost. Two women noted they had deferred consultation.

Other areas of sexual health the women identified as concerns were prevention of sexually transmitted disease and sexual violence. Most participants described themselves as more likely now than in the past to take precautions to avoid STDs. Four of the women shared that they formerly used sex as a way to obtain housing, food, and especially drugs. Two reflected on how they had run higher risk for STDs as younger women, having “random sex” (Teniesha [age 53]) or simply not having sexual health “on my radar” (Allyson [age 55]). Most women indicated that they would now insist on using a condom in a sexual encounter, and several said they would go with new partners to get co-tested prior to sex. Not all the women were equally vigilant. Candice (age 66) said she prevents STDs through monogamy. Two other women indicated they would not use condoms with a current or future partner unless there was reason to think the partner was “dipping off” or having relations with other people.

Though specific concerns about violence and safety in current or future relationships were rarely raised, seven of the women described intense violence in their past relationships. One woman described a former partner who raped her after she “blacked out” and, when “I woke up the next day in a pool of my own blood, beat me again because I bled in the bed.” Another described an ex-husband who “shot me in the head […] [and] beat me every day before breakfast, lunch, and dinner.” When asked if there were prevention strategies or redflags they looked for now, two of the women said they believed their past experiences with abusive partners had left them with a “sixth sense” or extra awareness by which they could detect controlling, violent, or dishonest tendencies in others.

Sexual Desire and Sexual Activity

The second category in our sexual health framework was sexual desire and sexual activity. Although eight of the nine women were not currently active sexually and endorsed periods of abstinence lasting from three to 10 years, their desire for sex varied. Maria (age 54), Teniesha (age 53), and Jeri (age 56) said they experience no sexual desire at all now and rarely think about it. Brandi (age 57), who described herself as a sex worker of 37 years, said she was repulsed by the idea of being touched at all. Teniesha (age 53) attributed her lack of desire to the weight she gained in recent years and confessed, “I hate my body. I’m not sure that if I found ‘Mr. Lottery Winner’ I would take my clothes off.” In contrast, Maria (age 54) spoke wistfully about a past relationship in which “the sex was ultimate to me” and shared that she had been worried enough about her absence of sex drive to talk with her mother about it. Candice (age 66), Nancy (age 60), Allyson (age 55), and Stephanie (age 52) said their desire for sex seemed to them equal to or greater than what they experienced as younger women. Allyson described dreaming about sex and having sleep orgasms. The only currently sexually active participant was Candice (age 66). Candice described her current relationship as intensely sensual, involving much caressing and kissing, hand-holding, and full body massages with oils, wine, and music. This physical intimacy was both pleasurable and therapeutic, since the massages eased some of the pain Candice suffered from rheumatoid arthritis.

Sexual Wellness & Positive Intimacy

Sexual wellness and positive intimacy was the third main category in the SAGE framework. Subtopics included stability in intimate relationships and partners, intertwined functions of communication and comfort in sexual and intimate relationships, and roles of self-determination and self-esteem in sexual and intimate relationships.

Stability in Partners and Relationships.

Most women who described an ideal relationship or ideal partner emphasized their own increasing appreciation of stability. Stability translated as financial self-sufficiency, honesty or trustworthiness, consistency, and in some cases a family-orientation. Irena (age 52) explained that, from her perspective as a mature woman, an ideal partner would be “very strong-minded, very strong morals, very firmly planted on the ground. A stable, stable person.” Teniesha (age 53) said her ideal relationship now would be with someone “financially stable—just mostly financial.” We also heard the term “clean” from several women in relation to stability in an ideal partner, once in reference to recovery from substance dependency, once in terms of a partner’s sexual behaviors and health, and once related to what the participant described as her desire for a “nice” and “quiet” relationship—stable because uncomplicated. Allyson (age 55) and Stephanie (age 52) observed that an ideal partner would also be family-oriented, easily integrated into their families and willing to spend time with their children and grandchildren.

Communication and Comfort.

Communication and comfort were common and intertwined themes in the women’s descriptions of positive intimacy, where the pattern often appeared in a women’s longing for or fond remembrance of comfortable communication with former intimate partners. Irena (age 52), Teniesha (age 53), Allyson (age 55), Brandi (age 57), Candice (age 66), and Stephanie (age 52) each said how much they valued relationships in which they had had open, honest sharing of thoughts and feelings. This was not always about serious sharing and deep revelations. Several participants described appreciation of something like a relaxed and open companionability, where partners communicated affection through lightheartedness and fun. Ease or comfort was captured in the overall tone of ideal relationships, as when participants said that, in contrast with earlier eras of their lives, now they looked for a relationship or partner who was “quiet” (Teniesha [age 53]), “low-key” (Allyson [age 55]), or “laid-back” (Brandi [age 57]). Only one woman, Candice (age 66), described intimacy using a traditional semiotic of romance: “candlelight, flowers, soft music, my husband cooking for me, a little white wine, just a little soft kisses, you know, around my neck, a little dancing, you know, fooling around.”

Self-Determination.

Self-determination was a feature of ideal future partnerships for several women, often sharply contrasted with previous relationships in which partners used money, violence, or other means to control them. Jeri (age 56) said that, now, unlike the past, she looks for a “50/50 relationship,” in which she and her partner both make decisions. Self-determination referred to maintaining control over one’s space, time, and resources. Jeri (age 56), Teniesha (age 53), and Brandi (age 57) described ideal partners who would not prove a drain on their resources but would have their own separate homes and sources of income. Maria (age 54) admired a friend’s relationship with a partner of 10 years, in which both had kids of their own and “their own places. They don’t stay together but they get along fine.” Nancy (age 60) took the notion of self-determination in relationship to another level when she declared that in her view “no partner is the best partner,” adding that she gets her joy out of cooking for neighbors and taking care of herself.

Self-Esteem.

The women also referred to connections between positive intimacy and feelings of self-esteem or self-valuation, noting how the quality of their intimacy with others was tied to the way they saw or valued themselves. Several referred to having achieved a more positive perspective on relationships compared with earlier periods, because they now felt happier with themselves. Candice (age 66) said her earlier attempts to find intimacy had mostly been about finding herself, whereas now she feels “at one with myself” and better “able to be with others.” Stephanie (age 52) contrasted her present sense of self with a younger self, saying she feels more comfortable with her sexuality now than in the past when she said her drug addiction made intimacy impossible. For others, self-esteem, especially in regard to weight changes at midlife, acted as a barrier.

Overarching Themes

Influence of Life Experiences.

Some life experiences seemed to work in tandem to negatively impact women’s attitudes about sex and their perspectives on intimacy. These clustered experiences surfaced at points throughout the interviews, typically though not exclusively involving overlapping violence, grief, substance use, and sex exchange. Four of the women described partner rapes and/or past emotional and or physical abuse. Two detailed experiences of loss and bereavement they said affected their efforts to achieve intimacy with others. At the time of her interview, Maria (age 54) was looking forward to an intense, week-long, one-on-one program of “deliverance” that she was scheduled to undertake with her pastor to help her process the death of her partner several years earlier. Maria hoped the program would remove the “soul-ties” that she said acted as a barrier to new relationships. For Nancy (age 60), substances had been a way to cope with memories of intimate partner violence and the grief of losing contact with her twin sister. Drugs, sex, violence, and grief remained bound up together for Nancy, leaving her, in her own words, “damaged and scarred,” with “a wall built up and I ain’t gonna let nobody tear it down.”

Though none of the women in this study reported the current exchange of sex for money or other resources, four of the women described how as younger women they regularly traded sex for drugs or money. Stephanie (age 52), Teniesha (age 53) and Brandi (age 57) emphasized the pragmatic role of commercial sex in their earlier lives (Stephanie: “Sex was the one 24-hour/7-day-a-week guaranteed way to get a dollar”; Teniesha: “Years ago, if I was on drugs and I ran out, I could literally walk out my door and up the street and figure out drugs in 20 minutes […] as I got older, less honking, less men stopping. So that stopped.”). All four of the women who exchanged sex for drugs or money described ways in which violence and sex intersected for them, though the impact of those overlaps on their present-day attitudes about sex and intimacy varied. Brandi (age 57) was emphatic that four decades in sex work (her designation) left her at best indifferent to sex. Nancy (age 60), who suffers chronic neck and back pain from a stomping assault by a past sexual partner, said she gets more gratification from cooking special dishes to share with her neighbors than she would expect to find in an intimate partnership. In contrast, while Teniesha (age 53) and Stephanie (age 52) numbered off incidents of violence related to past drug use and sex exchange, including another stomping assault, a rape, and sodomy at knife-point, both were more affirmative about the prospect of separating sex from drugs and violence and more hopeful about future sexual intimacy.

Growing Older

A second and different cross-cutting theme in the interviews was the value the women put on being older, including what they took from their experiences and what they wanted to pass on to others. Participants reported a number of positive views about aging in general. Jeri (age 56) said, “I like being old. I mean, I’m getting more respect from people.” Candice (age 66) said she valued simply being older and “enjoy[ing] what I have put together” and emphasized wanting to “go older than this if I can.” Irena (age 52), Allyson (age 55), and Brandi (age 57) said they appreciated the knowledge and broad experience they gained over time, even though some of the experiences caused them pain. Several women reflected on how they found opportunities to use their life experiences to guide younger women in their families or neighborhoods. These participants described sharing with younger women lessons they had learned about sex and relationships (Jeri), substance abuse and recovery (Irena), and the importance of self-valuation (Brandi). Though some had concerns about the future, few of the women expressed regret about the past. Instead, the women described gratitude for having survived such rich, often tumultuous life experiences. As Brandi appreciatively mused, “I have seen a lot of things in my life, did a lot of things in my life, good and bad.” Gratitude was not the final word in the interviews though. In our last interview question, we asked the women what title they would give the current chapter of their sex lives. The women’s responses called into relief a range of qualities—humor, hope, wry insight, and playfulness—that threaded through the interviews: “Bring a leaf blower and remove all the cobwebs” (Teniesha); “Dead and gone” (Brandi); “To be determined” (Allyson); “The danger zone” (Maria); and “Absence makes the cootchie stronger” (Stephanie).

Discussion

In this exploratory study of sex, sexual health, and positive intimacy in adult women age 50 years and over who have a history of CLS involvement, we documented experiences and perceptions that clustered in three main categories: sexual health and health care, sexual desire and activity, and sexual wellness and positive intimacy, with most findings in the first and third categories. The women’s perspectives on sex as they aged were influenced by repeated though not uniform patterns of life experience among them. These involved substance use, violence, and sex exchange on the one hand and, on the other, a sense of evolution, a kind of retrospective mellowing and leaning toward gratitude or benefit-finding. In light of what we heard, we offer the SAGE model (Figure 1) as a tentative heuristic for further investigation, development, challenge, and ultimately intervention.

Figure 1.

SAGE Model

Sexual Health and Health Care

Menopausal Transition

Key findings included that most of the women felt they were past a period when sexual activity and intimate relationships put them at high risk for sexual health problems, though most were still interested in sex and aware of the need to protect their sexual health. Most of the women were in their 50s and were either in menopausal transition or in menopause. Several participants described talking with a health care provider or family member about sexual and reproductive health issues–mainly, hot flashes, weight gain, and mood changes. It was not evident whether their symptoms were more or less intense than other women experience, though it bears noting that research has found links between greater severity in vasomotor symptoms during menopausal transition and social determinants that are associated with CLS involvement, including anxiety, obesity, and low educational attainment (De Mello et al., 2021; Monteleone et al., 2018).

All the women in the SAGE study were living in the community at the time of the interviews, but many women who have CLS involvement will spend some part of the years of menopausal transition incarcerated. A handful of studies have examined the management of perimenopausal symptoms during incarceration (Jaffe et al., 2022; Jaffe et al., 2021; Schach et al., 2021). Jaffe et al.’s (2021) study with women incarcerated in a North Carolina state prison documented reports of women being ignored, dismissed, and in some cases punished for requesting supplies or other support for unpredictable, heavy periods and intense physical discomfort. A related study of the medical treatment of menopausal symptoms in prison found low rates of prescribing hormonal therapy (Jaffe et al., 2022). We could not find information about the treatment of symptoms of menopausal transition among women living in the community after incarceration. We do know that women with CLS involvement report disproportionate rates of mood and trauma disorders and chronic cardiovascular and metabolic conditions, conditions that can be amplified by hormonal shifts during transition (Santoro et al., 2021).

Sexual Health Risk Prevention

In protecting against HIV and STDs, screening for STDs and cervical cancer, and protecting against sexual assault, the older adult women in the SAGE study showed themselves to be keenly aware of the risks they took as younger women and shared strategies they now follow to avoid them. Notwithstanding these safeguarding intentions, research indicates that sexually active middle and older adults may need additional reinforcement in the importance of using condoms, dental dams, or other barrier protection (Lewis et al., 2020). Experts have recommended that older adult women be assessed routinely for sexual health education needs and screened for gonorrhea and chlamydia as well as HIV when they become sexually active with a new partner (Granville & Pregler, 2018). Up to age 66, women should be tested as recommended for high-risk human papillomavirus (HPV) and/or receive Papanicolaou testing (Meites et al., 2019). We did not survey women about their HPV, cervical cancer, or other sexual health screening directly, but most women in our study referred to at least one screening or health care encounter with a health care provider in recent years in which they discussed sex or sexual health. More research is needed to say whether or to what extent this openness distinguishes the group from women without a history of CLS involvement, though other research has found that after age 50 women in general tend not to talk to their providers about sex (Bergeron et al., 2017).

Sexual Wellness and Positive Intimacy

The SAGE framework embraces a central tenet of both the sexual health framework and sexual wellness model, namely, that sexual health is not only about avoiding sexual risk and safety. Sexual health is also about positive sexuality: healthy intimacy, sexual self-expression, sexual self-determination, sexual justice, sexual self-esteem, and so on (Mitchell et al., 2021). For the women we interviewed, the positive facets of sexual health were most evident in passages in which women expressed their growing appreciation for intimate partnerships that featured equality, comfort or calm, and affirmative communication. The women in this study mostly stressed satisfaction with having arrived at a place of hard-won stability and expressed a longing for relationships that would contribute to or support their sense of wellbeing and self-sufficiency. We heard relatively little anxiety about aging in general, perhaps because the women’s previous life experiences were so challenging. Studies conducted with community samples have identified ways that middle and older adulthood can be especially tough for women, bringing upheavals in relationships, intensified pressure on work-life balance, increasing health issues, and shifting roles at work and home (Thomas et al., 2018). Our findings seemed more congruent with results in Barrett and Toothman’s (2018) study of aging-related anxiety in women, which found that more positive outlooks on aging were associated with older age, minority racial and ethnic identity, lower socioeconomic status, and better health and social relationships. Many of the SAGE interviews were distinctive for benefit finding, the identification of positive elements in otherwise challenging experiences. Along with social engagement, social support, and increased physical activity, benefit finding has been identified as protective against poor mental health in older adults (Cassidy & Doyle, 2018). We saw benefit finding in the appraisals women made specifically about growing older—which we asked for (“What do you value most about being older?”)—but also more generally in their perspectives on troubles they had lived through and where they found themselves now. In developmental terms, Erikson et al.’s (1994) pychosocial developmental theory seems especially applicable. The interviews often traced out—in terms conditioned by the women’s complex social context and experiences—their evolving struggles around intimacy in early adulthood; midlife investments and involvements of care; and, perhaps in keeping with accelerated aging, the integrations associated with wisdom in older age.

Implications and Recommendations

The SAGE study contributes a multifaceted, context-specific framework in which to begin to think about what sex and sexuality mean to older adult women who have experienced incarceration and how we might best support them as they form relationships and seek intimacy as they age. The sexual health and sexual health care component, for example, points to the importance of offering routine support of older adult women’s sexual health—through screening, education, resources, and referrals. Since older adult women with CLS involvement may struggle with regular access to health care due to poverty, unstable housing, transportation, and other issues, it may be necessary to integrate sexual health promotion and education into a range of health and social service encounters to increase points of contact and ease of follow up. Many CLS-involved women also pass in and out of incarceration over time, so universal standards of care and practice guidelines for older adult women during incarceration should be established across correctional systems to help ensure women’s holistic health needs are met and their human rights respected. Such care should include no-cost STD screenings and cervical cancer screenings when appropriate, sexual health education and positive intimacy promotion, and the assessment and treatment of needs related to menopausal transition.

The sexual desire and sexual activity and the sexual wellness and positive intimacy components of the model stress that older adult women with a history of CLS involvement continue to desire sex and long for opportunities to express their sexuality and/or enjoy intimacy with others. Peer-led, faith-based, and family-oriented approaches to sexual wellness and safety programming should be explored in the community both with and for this group. Efforts to address the sexual wellness of older women with CLS involvement should strive to be sexual- and gender-minority inclusive, culturally aware, and responsive to the range of individual attitudes, experiences, and abilities and desire to engage. Always, such programming should take into account the possibility of past trauma, substance abuse, and other life circumstances often associated with CLS involvement. Finally, if we take seriously the idea that incarceration broadly impacts women’s health and wellbeing and that sexuality is not an adjunct to but a key part of older women’s health, we must also question the effects on women of blanket prohibitions against sexual expression and activity among people while incarcerated, including measures like the Prison Rape Elimination Act (PREA) of 2006 (Smith, 2006). PREA’s application in ways that render off-limits all sexuality and positive intimacy, including consensual sex between people who are incarcerated and between people who are incarcerated and their visitors, should be scrutinized closely for its impact on human rights and well-being (Smith, 2006). Alternative approaches to ensuring sexual safety of people in custody other than universal abolishment deserve exploration (Struckman-Johnson et al., 2013).

Limitations

The SAGE study was conducted in the first year of the SARS-CoV-2 pandemic, so all interviews were by phone. We struggled in several ways with technology. Phone connections were frequently unclear and calls disrupted. Emailing consent forms and emailing and texting gift card codes proved challenging. Phone interviews eliminated visual cues and reduced opportunities for observation of the women’s environment. In some cases, the medium constrained verbal cues and complicated rapport-building. Even so, the interviews offered rich and varied information and achieved geographic and some racial diversity. Further interviewing might extend and deepen that base by including more participants in their 60s, 70s, and if possible 80s; participants who can share perspectives from gender- and sexual-minority standpoints; and representation of Hispanic women, since that group, like non-Hispanic Black women, is disproportionately incarcerated in the U.S. (The Sentencing Project, 2022). Finally, this study did not include any women who were currently incarcerated. Interviewing women during an incarceration is logistically difficult in the best of times; during the shut-down, it was impossible. Future work to understand and promote sexual health in older adult women with CLS involvement, it is hoped, will be able to include those voices as well.

Conclusion

The SAGE model reflects perspectives and experiences related to sexuality and sexual health shared with us by women whose lives have been disrupted by criminal legal system involvement and life circumstances associated with it. The model is offered in the hope that it will inform future research and programming to decrease sexual health risk among older adult women and increase opportunities and support for them as they develop positive sexual or intimate relationships.

Data Sharing:

The data that support the findings of this study are available on request from the corresponding author, Amanda Emerson. The data are not publicly available due to their containing information that could compromise the privacy of research participants.