Abstract
Objectives
To determine if measures of successful-aging are associated with sexual activity, satisfaction, and function in older post-menopausal women.
Design
Cross-sectional study using self-report surveys; analyses include chi-square and t-tests and multiple linear regression analyses.
Setting
Community-dwelling older post-menopausal women in the greater San Diego Region.
Participants
1,235 community-dwelling women aged 60-89 years participating at the San Diego site of the Women's Health Initiative.
Measurements
Demographics and self-report measures of sexual activity, function, and satisfaction and successful aging.
Results
Sexual activity and functioning (desire, arousal, vaginal tightness, use of lubricants, and ability to climax) were negatively associated with age, as were physical and mental health. In contrast, sexual satisfaction and self-rated successful aging and quality of life remained unchanged across age groups. Successful aging measures were positively associated with sexual measures, especially self-rated quality of life and sexual satisfaction.
Conclusions
Self-rated successful aging, quality of life, and sexual satisfaction appear to be stable in the face of declines in physical health, some cognitive abilities, and sexual activity and function and are positively associated with each other across ages 60-89 years.
Keywords: Sexual Activity, Sexual Satisfaction, Sexual Function, Post-menopausal Women, Self-Rated Successful aging
Introduction
Sexual activity, function, and satisfaction have been posited as an integral component of overall well-being among post-menopausal women1;2. For example, higher levels of sexual activity have been correlated with better physical2;3 and mental health1, and higher levels of marital adjustment4. Similarly, higher sexual satisfaction has been associated with better mental health5, higher relationship quality4 and general psychological well-being6, while sexual dysfunction is less likely to occur among women in good physical and emotional health5;7-9.
Whether sexual activity, function, and satisfaction, which are influenced by physical, social, and emotional factors, are also associated with self-rated successful aging remains unknown. Previous work suggests that older adults' perceived successful aging relates to other indicators of cognitive, emotional, and physical health10;11. Here, we examined associations between self-perceived successful aging, other measures related to successful aging, and sexual activity, function, and satisfaction in a cohort of community-dwelling women (ages 60-89 years) enrolled at the San Diego site of the Women's Health Initiative (WHI) study who also completed a successful aging survey in 200512;13.
The WHI is a major ongoing research program that began enrollment in 1993 to address the most common causes of death, disability and quality of life in 161,808 generally healthy post-menopausal women14. A study originating from the Observational Study (OS) of the WHI evaluated potential correlates of sexual satisfaction, assessed with a single dichotomous item, in 46,525 sexually active women ages 50 to 79 years. This study found that sexual satisfaction was unrelated to physical health but modestly related to mental health15.
Based on prior reports, we hypothesized that sexual activity, function, and satisfaction, would decrease with age. We further hypothesized that measures of successful aging, including self-rated successful aging and quality of life, depressive symptoms, and SF36 physical, mental, and social functioning would be positively associated with higher sexual activity, function, and satisfaction in post-menopausal women, and that this association would remain significant across ages 60-89 years.
Methods
Study Population
The study sample includes women from the San Diego clinical center of the WHI, a large NIH-funded multi-center study of the predictors of morbidity and mortality among post-menopausal women16 who were followed for an average of seven years between 1994 and 2005. A detailed description of the WHI methodology is available in prior publications16. Inclusion criteria were post-menopausal status, plan to reside in the area for at least 3 years, no medical conditions predictive of survival less than 3 years or complicating disorders such as substance abuse disorders, and ability to provide written consent. The WHI included an observational study and three separate clinical trials, involving hormone replacement therapy, dietary modification, and calcium/vitamin D supplementation14;17. Women enrolled in the clinical trials were not eligible to enroll in the OS.
At their final study visit, 3,653 San Diego WHI subjects were invited to participate in a study of successful aging (SA). For enrollment, women were either consented at their final clinic visit or mailed the questionnaire and consent form. Overall, 2,017 women returned the SA survey questionnaire. We have previously published reports using data collected with this questionnaire12;13. For the current study, we conducted analyses on the subsample of 1,235 English-speaking women, aged 60-89 years old who returned the SA survey with a signed consent form and who were also administered the items from the sexuality questionnaire analyzed in this report. The Institutional Review Board of the University of California, San Diego approved this study.
Measures
Demographics
Participants' age and marital status were current at the time of the SA survey in 2004-2006. Educational attainment and ethnicity were obtained from the baseline (enrollment) visit of the WHI study between 1993 and 1998. All other measures were taken from the SA survey.
Measures related to Sexual Activity, Function, and Satisfaction
We developed the sexuality questionnaire by adapting items from the Female Sexual Function index and the McCoy Female Sexuality Questionnaire18;19 and adding additional items by consensus among investigators and in consultation with clinicians in the Departments of Geriatrics and Geriatric Psychiatry at the University of California, San Diego. We included items to measure access to a partner, sexual activity with or without a partner in the last six months, satisfaction with overall sex life, and five sexual functioning questions (sexual desire, sexual arousal, vaginal tightness, use of vaginal lubricants, and ability to climax).
Measures related to successful aging
The primary dependent variables, Self-Rated Successful Aging (SRSA) and Self-Rated Quality of Life (SRQL) were obtained by asking participants to rate themselves on a 10-point Likert scale, with 1 being least and 10 most successful. The SRSA item asked subjects to rate their own level of successful aging, whereas the SRQL item asked subjects to rate their quality of life in the current decade of life. While we have not previously published results using the SRQL, our prior work suggests that SRSA is related positively to physical and mental health-related quality of life11 and less severe depressive symptoms13. Secondary measures of social, physical, and mental health-related functioning were obtained using the social functioning component and the physical and mental health composite scores of the MOS-RAND SF-36 scale18. Depression was assessed using the Center for Epidemiological Studies Scale for Depression (CES-D)21.
Statistical Analysis
We examined the data for outliers, missing values, and normality. We computed summary statistics for demographics; differences in demographics were compared across three age groups (ages 60 to 69, 70 to 79, and 80 to 89) using chi-square tests. We also checked for differences in demographics between the full sample of 3,653 women in the WHI San Diego cohort and 1,235 women who answered the SA and sexuality questionnaires.
We compared the three age groups on frequency of sexual activity with or without a partner in the last 6 months, satisfaction with overall sex life, five sexual functioning items, and six successful aging-related variables, using chi-square tests. Finally, each successful aging measure was entered as a dependent variable in multiple linear regression models with sexual function, activity, or satisfaction as independent variables of interest along with marital/relationship status and age group. Sexual variables were interacted with age cohort to determine if the association between sexual and SA variables varied across age cohorts.
All tests were Bonferroni adjusted to control for inflated Type I errors due to multiple testing. Analyses were conducted in R version 2.10.
Results
Demographics
The study sample consisted of 1,235 women aged 60 to 89 years (mean=73.6, SD =7.2). The participants were predominantly Caucasian (89%) and 53% were married or in an intimate relationship at the time of the SA survey. Eighty-eight percent had completed high school and 79% had attended at least some college. Sixty-seven percent of women aged 60-69, 53% of women aged 70-79, and 33% of women aged 80-89 were married or living in an intimate relationship at the time of the SA survey; these age cohort differences were highly significant (p<0.001). Older age cohorts were more predominantly Caucasian (p<0.001), but did not differ in years of education.
Of the 3,653 women in the San Diego WHI cohort, 1,979 (54%) returned the SA survey; no significant demographic differences existed between the subjects responding to the SA survey and the full San Diego WHI cohort. Additionally, no significant demographic differences existed between subjects in the full San Diego cohort and the 1,235 women who responded to the sexuality questionnaire.
Age Differences in Sexual and Successful Aging Variables
The responses for sexuality questionnaire items are presented in Table 1. Sexual activity decreased significantly in older age cohorts. Of the women who were married or in an intimate relationship, 70% of women aged 60 to 69, 57% of women aged 70 to 79, and 31% of women aged 80 to 89 reported having had some sexual activity in the last six months. Thus, women married or living in an intimate relationship engaged in higher rates of sexual activity than women who were not living in such a relationship (p<0.001), though sexual activity in women married or living in an intimate relationship still decreased across age cohorts (p<0.001). No significant differences existed among age groups on reasons endorsed for not engaging in sexual activity. As seen in Table 1, women who had not engaged in recent sexual activity cited “lack of a partner” most often, followed by “partner is not able.” All five indicators of sexual functioning were negatively related to age. In contrast to sexual activity and functioning, satisfaction with overall sex life was not significantly different across age cohorts. Of the SA variables, three were significantly different across age cohorts: CES-D and the SF-36 Physical Health and Social Functioning Components (Table 2). SRQL, SRSA, and SF-36 Mental Health Component did not differ significantly across age cohorts.
Table 1. Comparison of Age Groups on Sexuality Questionnaire responses.
| Variable | Age Cohort (years old) | χ2 (DF)* | P | ||
|---|---|---|---|---|---|
| 60-69 (N=389) | 70-79(N=565) | 80-89(N=281) | |||
| SEXUAL ACTIVITY | |||||
| Has sex been a part of your life in the last 6 months, either with or without a partner? | |||||
| Yes | 201 (51.7%) | 184 (32.6%) | 38 (13.5%) | 83.9 (2) | <0.001** |
| No | 153 (39.3%) | 286 (50.6%) | 174 (61.9%) | ||
| Missing | 35 (9.0%) | 95 (16.8%) | 69 (24.6%) | ||
| Reason for sex not being a part of your life in the last 6 months. (Only those women that answered “No” to “Has sex been a part of your life in the last 6 months.”) | N=153 | N=286 | N=174 | ||
| Not interested | 21 (13.8%) | 33 (11.5%) | 23 (13.2%) | 12.7 (10) | 0.239 |
| Not able | 2 (1.3%) | 4 (1.4%) | 0 (0.0%) | ||
| Do not have a partner | 60 (39.2%) | 115 (40.1%) | 91 (52.3%) | ||
| Partner is not interested | 6 (3.9%) | 6 (2.1%) | 4 (2.3%) | ||
| Partner is not able | 38 (24.8%) | 81 (28.2%) | 38 (21.8%) | ||
| Other | 13 (8.5%) | 31 (10.8%) | 11 (6.3%) | ||
| Missing | 13 (8.5%) | 17 (5.9%) | 7 (4.0%) | ||
| SEXUAL SATISFACTION | |||||
| How satisfied have you been w/your overall sex life? | |||||
| Very dissatisfied | 55 (14.1%) | 55 (9.7%) | 25 (8.9%) | 9.1 (6) | 0.167 |
| Moderately dissatisfied | 57 (14.7%) | 79 (14.0%) | 26 (9.3%) | ||
| Equally to Moderately Satisfied | 165 (42.4%) | 199 (35.2%) | 105 (37.4%) | ||
| Very Satisfied | 89 (22.9%) | 143 (25.3%) | 69 (24.6%) | ||
| Missing | 23 (5.9%) | 89 (15.8%) | 56 (19.9%) | ||
| SEXUAL DYSFUNCTION | |||||
| Please rate how much, if at all, you have experienced the following in last 6 months: | |||||
| Sexual desire or interest | 72.0 (6) | <0.001** | |||
| Rarely or not at all | 123 (31.6%) | 214 (38.2%) | 142 (51.0%) | ||
| Some or the time | 188 (48.3%) | 212 (37.5%) | 66 (23.6%) | ||
| A lot of the time | 52 (13.4%) | 56 (9.8%) | 12 (4.2%) | ||
| Missing/Do not want to answer | 27 (6.9%) | 85 (14.5%) | 57 (19.4%) | ||
| Feeling sexually aroused (turned on) | 59.9 (6) | <0.001** | |||
| Rarely or not at all | 150 (38.6%) | 239 (42.3%) | 151 (53.7%) | ||
| Some of the time | 175 (45.0%) | 201 (35.6%) | 58 (20.6%) | ||
| A lot of the time | 32 (8.2%) | 35 (6.2%) | 7 (2.5%) | ||
| Missing/Do not want to answer | 32 (8.3%) | 90 (16.0%) | 65 (23.1%) | ||
| How often do you experience tightness of vagina? | 46.7 (6) | <0.001** | |||
| Rarely or not at all | 215 (55.3%) | 339 (60.0%) | 176 (62.6%) | ||
| Some of the time | 72 (18.5%) | 74 (13.1%) | 23 (8.2%) | ||
| A lot of the time | 45 (11.6%) | 27 (4.8%) | 8 (2.8%) | ||
| Missing/Do not want to answer | 57 (14.6%) | 125 (22.2%) | 74 (26.3%) | ||
| How often do you require the use of vaginal lubricants? | 31.6 (6) | <0.001** | |||
| Rarely or Very Rarely | 200 (51.4%) | 294 (52.0%) | 129 (45.9%) | ||
| Moderate | 16 (4.1%) | 33 (5.8%) | 11 (3.9%) | ||
| Often | 40 (10.3%) | 40 (7.1%) | 12 (4.3%) | ||
| Very Often | 59 (15.2%) | 37 (6.5%) | 8 (2.8%) | ||
| Missing | 74 (19.0%) | 161 (29.0%) | 121 (43.1%) | ||
| Ability to reach a climax (orgasm) | 86.0 (6) | <0.001** | |||
| Rarely or not at all | 100 (25.7) | 135 (23.9%) | 90 (32.0%) | ||
| Some of the time | 85 (21.9%) | 85 (15.0%) | 19 (6.8%) | ||
| A lot of the time | 123 (31.6%) | 115 (20.4%) | 25 (8.9%) | ||
| Missing/Do not want to answer | 81 (20.9) | 230 (40.7%) | 147 (52.3%) | ||
Missing data category not included in χ2 tests
Significant after Bonferroni correction p=0.05/7=0.007
Table 2. Comparison of Age Groups on Successful Aging Variables.
| Variable (Range) | Age Cohort (years old) | F (df1,df2) | P | ||
|---|---|---|---|---|---|
| 60-69N=389Mean (SD) | 70-79N=565Mean (SD) | 80-89N=281Mean (SD) | |||
| Primary Outcomes | |||||
|
| |||||
| Self-Rated Successful Aging (1-10) | 8.2 (1.4) | 8.2 (1.4) | 8.0 (1.6) | F=2.5 (2,1) | 0.079 |
|
| |||||
| Self-Rated Quality of Life (1-10) | 8.0 (1.8) | 8.4 (1.8) | 8.2 (1.8) | F=0.9 (2,1) | 0.426 |
|
| |||||
| Secondary Outcomes | |||||
|
| |||||
| MOS-RAND SF-36* social functioning component(1-100) | 91.4 (17.1) | 89.6 (18.1) | 83.1 (21.4) | F=17.6 (2,1) | <0.001*** |
|
| |||||
| MOS-RAND SF-36* physical health component (1-100) | 46.8 (10.1) | 43.1 (11.3) | 37.8 (12.0) | F=52.5 (2,1) | <0.001*** |
|
| |||||
| MOS-RAND SF-36* mental health component (1-100) | 56.2 (6.6) | 56.8 (7.1) | 56.0 (9.0) | F=1.3 (2,1) | 0.280 |
|
| |||||
| CES-D** (0-60) | 5.8 (6.4) | 6.3 (5.5) | 8.7 (7.1) | F=15.9 (2,1) | <0.001*** |
RAND Medical Outcomes Study, 36-Item Short Form Survey
Center for Epidemiologic Studies Depression Scale
Significant after Bonferroni correction p=0.05/6=0.008
Association between Sexual and Successful Aging Variables
Satisfaction with overall sex life was positively associated with SF-36 Mental Health Component (t=2.96, p=0.003) and SRQL (t=6.80, p<0.001), but negatively associated with and CES-D (t=-2.88, p=0.004). Sexual activity was positively associated with SRSA (t=3.14, p=0.002) and SRQL (t=3.44, p<0.001).
With respect to the sexual functioning items, SRSA was positively associated with increased levels of sexual desire (t=2.88, p=0.004) and increased ability to climax (t=3.73, p<0.001), and significantly related to sexual arousal (t=2.56, p=0.01) before, but not after, the Bonferroni correction. SF-36 Social Functioning was positively associated with sexual arousal (t=3.01, p=0.003), but only in women who were married or otherwise in an intimate relationship. Likewise, SRQL was positively associated with sexual desire (t=2.89, p=0.003) and sexual arousal (t=3.27, p=0.001), but only in women who were married or in an intimate relationship.
Discussion
As predicted, sexual activity and functioning decreased with age, a result consonant with other reports3;5;23-25. However, and contrary to our first hypothesis, sexual satisfaction was not significantly associated with age. In this regard, the literature has been inconsistent in describing the relationship between age and sexual satisfaction in older women, with some studies reporting a positive15;24 and others reporting a negative relationships5;26;27. In our sample, levels of sexual activity and functioning vary significantly across age cohorts whereas sexual satisfaction does not. Similarly, most SA measures, including physical and mental health, declined with increasing age. Subjective assessments were exceptions to this trend. Levels of self-rated quality of life and successful aging remained substantially unchanged across age cohorts, mirroring the lack of change across age cohorts in self-rated sexual satisfaction.
That subjective appraisals of quality of life, successful aging, and sexual satisfaction did not decline in parallel with physical health, some cognitive abilities, and decreases in sexual activity and functioning is consistent with observations that self-rated health changes little with age whereas objective health indicators do show age-associated decline28. In other words, perceived quality of life, successful aging, and sexual satisfaction appear to be stable in the midst of age-associated changes in physical, mental, and sexual health. Interestingly, positive associations between successful aging and sexual variables were also strongest for subjective measures, in particular self-rated quality of life and sexual satisfaction. Self-rated quality of life and successful aging were also strongly associated with sexual desire and arousal in those women who were married or who had an intimate partner. These positive associations remained significant across all age cohorts, including women aged 80-89 years.
There are several limitations to this study. First, the data are cross-sectional and hence aging cannot be disentangled from age cohort effects; moreover, it requires longitudinal data to determine causal or directional relationships, if any, among successful aging and sexual variables. Second, the WHI San Diego cohort is largely Caucasian and highly educated and the results may not generalize to ethnic minorities or to other socioeconomic strata. Third, a minority of women in the San Diego cohort (34%) replied to the sexuality questionnaire and hence these results may reflect response biases. Fourth, obtaining valid sexual functioning measures from women who may have had variable lengths of time since last sexual activity can be problematic (e.g., they may be subject to recall bias). Finally, the current report uses self-report measures in post-hoc analyses, liable to be inferior to analyses of interviewer-administered data from studies a priori designed to address issues regarding successful aging and sexual variables. As such, future studies will be needed to address these limitations and also assess more subtle aspects of sexual function and successful aging.
Sexual activity, satisfaction, and functioning are positively associated with higher self-rated successful aging and quality of life across age groups in the sample. Moreover, self-rated quality of life and sexual satisfaction are strongly associated with each other and appear to be stable in the face of declines in physical health, certain cognitive abilities, and sexual activity and function.
Acknowledgments
We would like to thank Ruth O'Hara, Ph.D. and Meryl Zwanger, M.A. for their assistance during the preparation and review of this manuscript. We would also like to thank the editor and anonymous reviewers for their comments and suggestions, which greatly improved the manuscript.
This work was supported, in part, by grants from the National Institute on Mental Health (MH080002, MH076981), the National Institute on Aging (AG26757), and by the UCSD Sam and Rose Stein Institute for Research on Aging. The WHI program is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, U.S. Department of Health and Human Services through contracts N01WH22110, 24152, 32100-2, 32105-6, 32108-9, 32111-13, 32115, 32118-32119, 32122, 42107-26, 42129-32, and 44221.
Short List of WHI Investigators
Program Office: (National Heart, Lung, and Blood Institute, Bethesda, Maryland) Jacques Rossouw, Shari Ludlam, Joan McGowan, Leslie Ford, and Nancy Geller. Clinical Coordinating Center: (Fred Hutchinson Cancer Research Center, Seattle, WA) Ross Prentice, Garnet Anderson, Andrea LaCroix, Charles L. Kooperberg; (Medical Research Labs, Highland Heights, KY) Evan Stein; (University of California at San Francisco, San Francisco, CA) Steven Cummings. Clinical Centers: (Albert Einstein College of Medicine, Bronx, NY) Sylvia Wassertheil- Smoller; (Baylor College of Medicine, Houston, TX) Haleh Sangi-Haghpeykar; (Brigham and Women's Hospital, Harvard Medical School, Boston, MA) JoAnn E. Manson; (Brown University, Providence, RI) Charles B. Eaton; (Emory University, Atlanta, GA) Lawrence S. Phillips; (Fred Hutchinson Cancer Research Center, Seattle, WA) Shirley Beresford; (George Washington University Medical Center, Washington, DC) Lisa Martin; (Los Angeles Biomedical Research Institute at Harbor- UCLA Medical Center, Torrance, CA) Rowan Chlebowski; (Kaiser Permanente Center for Health Research, Portland, OR) Erin LeBlanc; (Kaiser Permanente Division of Research, Oakland, CA) Bette Caan; (Medical College of Wisconsin, Milwaukee, WI) Jane Morley Kotchen; (MedStar Research Institute/Howard University, Washington, DC) Barbara V. Howard; (Northwestern University, Chicago/Evanston, IL) Linda Van Horn; (Rush Medical Center, Chicago, IL) Henry Black; (Stanford Prevention Research Center, Stanford, CA) Marcia L. Stefanick; (State University of New York at Stony Brook, Stony Brook, NY) Dorothy Lane; (The Ohio State University, Columbus, OH) Rebecca Jackson; (University of Alabama at Birmingham, Birmingham, AL) Cora E. Lewis; (University of Arizona, Tucson/Phoenix, AZ) Cynthia A. Thomson; (University at Buffalo, Buffalo, NY) Jean Wactawski-Wende; (University of California at Davis, Sacramento, CA) John Robbins; (University of California at Irvine, CA) F. Allan Hubbell; (University of California at Los Angeles, Los Angeles, CA) Lauren Nathan; (University of California at San Diego, LaJolla/Chula Vista, CA) Robert D. Langer; (University of Cincinnati, Cincinnati, OH) Margery Gass; (University of Florida, Gainesville/Jacksonville, FL) Marian Limacher; (University of Hawaii, Honolulu, HI) J. David Curb; (University of Iowa, Iowa City/Davenport, IA) Robert Wallace; (University of Massachusetts/Fallon Clinic, Worcester, MA) Judith Ockene; (University of Medicine and Dentistry of New Jersey, Newark, NJ) Norman Lasser; (University of Miami, Miami, FL) Mary Jo O'Sullivan; (University of Minnesota, Minneapolis, MN) Karen Margolis; (University of Nevada, Reno, NV) Robert Brunner; (University of North Carolina, Chapel Hill, NC) Gerardo Heiss; (University of Pittsburgh, Pittsburgh, PA) Lewis Kuller; (University of Tennessee Health Science Center, Memphis, TN) Karen C. Johnson; (University of Texas Health Science Center, San Antonio, TX) Robert Brzyski; (University of Wisconsin, Madison, WI) Gloria E. Sarto; (Wake Forest University School of Medicine, Winston-Salem, NC) Mara Vitolins; (Wayne State University School of Medicine/Hutzel Hospital, Detroit, MI) Michael S. Simon.
| Elements of Financial/Personal Conflicts | L.C | W.T. | I.V | C.D. | M.A. | D.J. | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Yes | No | Yes | No | Yes | No | Yes | No | Yes | No | |
| Employment or Affiliation | X | X | X | X | X | X | ||||||
| Grants/Funds | X | X | X | X | X | X | ||||||
| Honoraria | X | X | X | X | X | X | ||||||
| Speaker Forum | X | X | X | X | X | X | ||||||
| Consultant | X | X | X | X | X | X | ||||||
| Stocks | X | X | X | X | X | X | ||||||
| Royalties | X | X | X | X | X | X | ||||||
| Expert Testimony | X | X | X | X | X | X | ||||||
| Board Member | X | X | X | X | X | X | ||||||
| Patents | X | X | X | X | X | X | ||||||
| Personal Relationship | X | X | X | X | X | X | ||||||
Footnotes
Conflict of Interest: The authors do not have financial conflicts of interest to report.
Contribution of Authors: Conception and Design: Dilip Jeste, Colin Depp, Lindsey Charo, Wesley Thompson. Drafting of Manuscript: Lindsey Charo, Wesley Thompson, Ipsit Vahia. Statistical Analyses: Wesley Thompson. Acquisition of Data: Matthew Allison. Interpretation of Data: Ipsit Vahia, Matthew Allison. The authors thank Rebecca Daly for her invaluable assistance with the data management and for the assistance of Meryl Zwanger in editing the manuscript.
Sponsors Role: The sponsors did not play any role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript. The views expressed are those of the authors and do not necessarily reflect those of the University of California, San Diego Department of Psychiatry.
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