hands of three different people, three different ages, crossed
LGBTQ Health Bookshelf

Act Three

Too often, life’s final act is viewed through lenses that are ground by society and fitted by medicine. A geriatrician argues that this needs to change.

Over two thousand years ago, Aristotle defined a whole as “that which has a beginning, a middle, and an end.” He showed that in three-act dramas each part contains multiple scenes and serves a unique purpose. Most human lives follow a similar progression, from setup through complications to conclusion. Until recently in human history, people’s individual dramas often ended early in the first act and certainly before the curtain fell on what we now consider Act II. The average life span was thirty to forty years, with childbirth, accidents, and infections routinely cutting lives short. These days, average longevity has doubled. With so much more time, each act contains more scenes, and most of us make it to Act III. Now, alongside childhood and adulthood, the vast majority of us can also expect a third act, or elderhood, that begins at sixty or seventy and lasts for decades. This third act is not a repeat of the first or second. More often, it is in life what it is in drama: the site of our story’s climax, denouement, and resolution.

Those last two scare us. We desperately want our elderhood to be long, meaningful, and satisfying, yet most of us refuse to approach it with the same shameless ambition we reflexively accord childhood and adulthood. For the first years of my career, I thought I understood old age and how to create a comfortable, meaningful Act III for my patients. But once my parents entered their eighties and I turned fifty, I realized I had been mistaken. I found myself making all the same sorts of cracks and feeling all the same feelings about aging as everyone else.

cover of Elderhood, a book by Louise Aronson
Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life by Louise Aronson. Published in 2019 by Bloomsbury Publishing.

Up until that point, I had believed that geriatrics, with its specialized tools and knowledge, had all the answers about old age. But if geriatrics adequately addressed old age, wouldn’t the rest of medicine and everyone else have adopted our philosophy and strategies? Clearly, geriatrics was to elderhood what we doctors call “necessary but not sufficient,” and I began to wonder what I was missing …

For most of us, Act III is long and varied. If we see it differently, our feelings about it might also change. And if we see and feel differently about old age, we can make different choices, ones that change our experience of elderhood for the better.

Sexy

Television serves as a rose-tinted mirror held up to our societal obsessions, conceits, and fantasies. Increasingly, it is weighing in on the topic of old age.

In the show Grace and Frankie, Jane Fonda (age seventy-nine in the third season) and Lily Tomlin (age seventy-seven) played scenes that often included jokes about one’s hearing and the other’s memory loss. Meanwhile, their now romantically partnered gay ex-husbands, Martin Sheen (age seventy-six) and Sam Waterston (also age seventy-six), after years of secrecy, at last let themselves come out to family and friends. Age liberated them from the conventions to which they submitted for decades, and the men finally claimed their true sexuality and identities.

In contrast to most casting, the male leads are younger than the females. Not by much, but Hollywood usually pairs men with women ten to thirty years their junior. Apparently, the rules of the game change in old age. This is Hollywood’s traditional approach to heterosexuality across the life span: For the most part, teens fall for teens and young adults for young adults. In middle age, things change. Men fall for younger women, and women become mommies and bosses—roles commonly presented as mutually exclusive with sexuality and romance. In old age, the playing field evens up again, or maybe women gain a slight advantage. But it’s not just women who are misrepresented. The association of manhood with virility is so strong that older men are put in a lose-lose situation, either portrayed as impotent in all senses of that word or described in language that suggests their sexuality is surprising, inappropriate, unbecoming, or repulsive. Jokes along the lines of “Grampa got game!” (said of Robert De Niro in the movie The Intern) commend thoughts and behaviors considered normal from age twelve through adulthood.

Despite its charms, Grace and Frankie sends mixed messages. The leads are all attractive, even if Fonda and Tomlin would not have been considered aesthetic peers in decades past. (Old is old is old …) None of the characters have completely gray or white hair, and, given the commonness of hair loss in male old age, it’s hard to believe that the selection of two still follicularly endowed male actors isn’t meant to signal ongoing vitality. We are not the first generation to link sexuality with youth or to downgrade women years or decades before men.

A widowed friend in her seventies is often assumed to be much younger than she is. She has a great brain, a good sense of humor, flawless grooming, and a full life, but men don’t look at her much anymore, and she hates that. When I last saw her, she regaled me with stories about her recent adventures in online dating. Her conclusion: “I don’t want to be a nurse or mommy and only men looking for one of those look at me.” The ones who might have interested her were looking downward chronologically, not across.

Other straight women find relief in the sexual invisibility of their old age. This has less to do with a loss of interest in sex than with the pleasure of shedding the need they once felt to groom, preen, perform, and perpetually prove their worth by asserting their attractiveness to the male gaze. Those women still make an effort to look good but are happy to worry less about attractiveness, to have more time for other pursuits, to feel safer out in the world, and to celebrate a more honest and accurate alignment of their inner and outer selves.

Some have argued that because of gay male culture’s focus on a young, buff, and beautiful version of sexual attractiveness, 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.

Old age will only be respected if it fights for itself, maintains its rights … and asserts control over its own to its last breath.
—Cicero

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 way:

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.”

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, 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 incontinence 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. …

————

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.

We’re all old people in training.
—Joanne Lynn, MD

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.” 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.

Bodies

You don’t have to be a doctor to recognize that the body changes with age, and you don’t have to be officially old to know from personal experience that many of those changes are unwelcome. The physical and physiological changes that accrue to “old” begin subtly and early, in a person’s thirties or forties, and at some variable point in our sixth, seventh, or eighth decade, we pass the physical, social, and legal thresholds of old age. The negative parts of this transformation—the losses—initially require adaptation, then limitation, and sometimes, finally, renunciation or the need for work-arounds. None of us want a cane, much less a walker, or help with finances or driving or grocery shopping. And uniformly, we don’t want to end up hopeless, helpless, and institutionalized—most people’s image of advanced old age and, often enough, at some late point, its reality. If you also consider that—unlike the terrible twos, a traumatic adolescence, a squandered young adulthood, or a midlife crisis—what follows being old is death, it becomes clear how old age achieved its current reputation.

Healthy, able-bodied people often say they wouldn’t want to live with grave disability. Meanwhile, a majority of people who become disabled—after an adjustment period—report good and, not infrequently, very good quality of life. Yet, when I suggest to friends in their seventies and eighties that a good part of the suffering in old age is manufactured by our policies and attitudes, they work hard to fill their expressions with nothing but curiosity and interest. In their eyes, I see suspicion, disbelief, and several unspoken retorts: She’s too young to understand. Facts are facts, biology is biology, and we are all destined for more or less the same downward slide to oblivion.

Their reaction depends a bit on what kind of day or week or month they’re having. Being sick or in pain or the recent death of a friend colors everything, and each of those things is increasingly common with age. People who are relatively healthy but have the pain or limitations of chronic diseases wonder what will happen next, and when. They worry about suffering and dying, about the loss of the people they love best, about being alone and about being gone. Those who are frail and sick or heading that way worry they won’t die as soon as they’d like to. Others, with lists of ailments and medications long enough to unfurl like scrolls, fight to stay alive, even as ever greater proportions of their days are devoted to the basics of body tending: hygiene, and food, and medications.

People with highly restricted lives—the sorts of people in our housecalls practice, for example—lament less their lives’ small stages than the accompanying isolation. The official term for the space we move through in the world, whether large or small, is life-space. Mine extends to continents; theirs is often limited to their home, a single room, or a bed. They would like to get out, to again be the sort of person who could or would go more places. But that’s not the source of their greatest hardship. What they miss most, what they are starved for, is engagement, touch, conversation, and connection, those basics of being human that come in just above our needs for food, shelter, and safety on Maslow’s hierarchy. Much has been made of what missing touch and connection did to Romanian orphans. The impact of isolation in old age, of never or rarely being touched or talked to or loved, is less formative but no less profound. Social isolation and loneliness worsen physical and mental health, leading to nursing home placement and premature death. In the UK, a young man spent a week alone in an apartment as part of the Loneliness Project, and although he started out okay, over the week he became increasingly frustrated, bored, despondent. He focused on small daily tasks, little things gnawed at him, he tried to turn off his brain, and he watched TV or went to bed for lack of other options.

————

On FaceTime, my mother, in the lobby at her gym, holds her phone midway between her mouth and ear. In public, she doesn’t want it too loud, but in each of the last two years, she has consulted an audiologist, wondering whether the time for a hearing aid has arrived; on her most recent visit, they agreed she was getting close. I’m on my computer. Her cheek, one eye, and parts of her nose and lips fill its large screen. This close, the softness of her skin seems visible. It has a laxity, a slight droop, creases, and texture. It is subtly colorful, a canvas of tans, pinks, and off-whites. She has blemishes, too, darker patches hinted at beneath the makeup she has put on to hide them. At the corner of her lips, I see an irregularity, and the doctor in me considers diagnoses to explain it. I smile at the sight of the small pale pouch under her eye; she hates it, just as her father in his old age hated his. For fifteen minutes, I talk to my mother while watching this video of the side of her face. It’s no less captivating than the several art films I have recently seen, and no less beautiful.

For age is opportunity no less / Than youth itself, though in another dress
—Henry Wadsworth Longfellow

Do I imagine I see the softness of her cheek because I have kissed that cheek and know the feel of it on my skin? Is it because her cheek is so familiar—likely the first skin I kissed over a half century ago—and because I love my mother? Or is it because I know in some essential way that if something looks as her cheek does, it’s soft to the touch, warm, yields on impact with a gentleness that is inviting and comforting. A younger cheek, taut and smooth, is more like a trampoline; a touch doesn’t sink in so much as bounce off. Later than night, climbing into bed, I realize that, for me, faces are like bedsheets in winter. My favorites are our oldest, soft and welcoming from years of use. When we use the newer ones, my heart sinks. They are nicer to look at but crisp and cold on my skin. …

Coda

A good life, like a good story, requires a beginning, a progression, and an ending. Without those defining elements, it feels partial, even tragic; it lacks shape, purpose, and meaning. The end may be hard and sad, but even when we don’t want a story to end, the best ones leave us with a sense of completion and satisfaction.

The left-brain fixers among us offer only instruments. Sometimes these are lifesaving or life enhancing; other times, their unintended consequences overshadow any benefits. Without due diligence about who chooses the questions and tools, who benefits, and who might be gravely harmed, what appears to be progress can be anything but. Science and technology can only ask and answer certain sorts of questions. Those instruments, although now considered synonymous with progress in both medicine and life generally, will become socially and morally responsible only when they are paired at the outset with equal consideration of their origins, intent, and impact on people of all ages and backgrounds.

Events are judged not on their entirety but on their moments of peak intensity and on their endings. And what is life but a long, messy, awful, wonderful event? Elderhood is life’s third and final act; what it looks like is up to us.

Louise Aronson, MD ’92, is a geriatrician, educator, and professor of medicine at the University of California, San Francisco. This excerpt is from Aronson’s New York Times bestseller, Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life, 2019. It appears with permission from the author and her publisher, Bloomsbury Publishing.

Images: Dbright/Signature/Getty (top); Hadynyah/Signature/Getty; Maya Rucinski-Szwec (book). All quotations appear in Elderhood.