DIFFICULT MORAL QUESTIONS

Question 29: What sexual activity is permissible for elderly married couples?

After teaching natural family planning (NFP) for several years, I recently began working as a nurse practitioner in a Catholic home for the elderly. The staff here has undertaken to improve health care for the residents without increasing costs. We are trying to reduce the rate of hospitalizations and contacts with physicians, especially specialists, by managing residents’ care, and at the same time supply some of the services physicians have been providing, promote more effective cooperation by patients, and answer many of the questions a doctor otherwise would answer. I am getting to know our residents personally, and they are beginning to trust me and talk about their problems.

About one-third of our residents are married couples, who occupy spacious double rooms with private bathrooms. Having heard that I had taught NFP, several couples have asked me about difficulties they have with marital intercourse. The men are more or less impotent. The wives are postmenopausal, so that contraception is never an issue, but the couples’ attempts to deal with the problem of impotence do raise some moral questions.105 I hope you will be able to answer them, since we do not have a resident chaplain, and, though the assistant at the parish is here part time, he is not sure about these questions and is too busy to look into them.

(1) In a few cases, where the husbands are completely impotent, the couples no longer attempt intercourse. Instead, they only snuggle and fondle each other’s genitals. They experience some sexual arousal and find it satisfying, though neither has an orgasm. Is this permissible? I think it is, but the priest is not sure, since these couples have no prospect of having intercourse.

(2) One husband can obtain an erection, but only if his wife stimulates his penis manually or orally, and she prefers to do it orally. They prepare beforehand by applying a lubricant to the wife’s labia and vagina to facilitate intercourse; she stops the stimulation just before he climaxes; they have vaginal intercourse during which he immediately ejaculates; and he then stimulates her manually to orgasm. Is this permissible? The priest, though not sure, thinks the oral-genital contact and the manual stimulation of the wife to orgasm may be wrong.

(3) Another husband’s complete impotence greatly frustrated his wife, who has been on estrogen replacement therapy since menopause and wants regular intercourse. The couple are quite determined, and have tried various remedies for impotence. To avoid the disadvantages of other approaches, they are using a vacuum device placed over the penis so that the air pressure surrounding it is lowered, bringing on an erection, which is then sustained by placing an elastic constriction ring around the base of the penis. The vacuum device then is removed, and they engage in satisfying intercourse. However, the constriction ring not only keeps blood in the penis but interferes with ejaculation; when the husband removes the ring after withdrawal, quite a bit of semen flows from his penis. The question is: If no semen reaches the wife’s vagina—perhaps a little does but they are not sure—are this couple engaging in sinful, nonmarital acts? I have no idea what to tell them.

(4) In a few other cases where the husband is totally impotent, couples have tried various remedies without finding any satisfactory. Is it permissible for such a couple to stimulate each other to orgasm without any genital contact? I do not think it is. But is it permissible if the couple make genital contact so that the husband ejaculates at the mouth of the vagina, and he then manually stimulates his wife to orgasm?

Analysis:

Several questions are asked about sexual activity within marriage. Questions (1), (2), and the first part of (4) can be answered by applying accepted norms for marital sexual activity. The other questions cannot be answered except by identifying the minimal condition a couple’s outward behavior must meet to be the performance of an instance of intercourse as a moral species of action. In my judgment, the minimal condition is that the couple’s behavior be the performance required for a reproductive-type act. By that criterion, intercourse with the use of a constriction ring to overcome impotence is true sexual intercourse—and so can be marital intercourse—if any semen whatsoever reaches the vagina, which may be assumed in case of doubt. Similarly, if, but only if, an impotent husband can ejaculate some semen into the vagina, the couple are capable of marital intercourse—which answers the second part of (4). An adequate response to these questions should also include an indication of other requirements for marital intercourse, so that the proposed reply will not be misinterpreted as reducing the marital act to its minimal behavioral conditions.

The reply could be along the following lines:

Your questions are important ones, since the moral issues they raise are by no means trivial, and answers are needed for the peace of conscience and happiness of many elderly people. Moreover, many couples now live longer than formerly, and Catholic moralists have devoted very little attention to these matters.106 The marital sexual activity and satisfaction of elderly couples remain significant goods, both in themselves and for their contribution to other aspects of their lives. Therefore, I welcome these questions, even though dealing with them will require a rather clinical discussion that may provoke reproach or ridicule from people lacking your training and sympathy for those needing help.

Men usually should consult a physician about impotence. As you undoubtedly know, in many cases it is either a side effect of medication or a symptom of some illness, such as diabetes, that might be discovered by a thorough examination and remedied by suitable treatment. However, given your professional role, I assume you have seen to it that these men are receiving appropriate health care.

Sometimes impotence results from a man doing something he should not, such as drinking too much or obtaining sexual satisfaction apart from intercourse by masturbating. Gently mention such possibilities and encourage the men you deal with to examine their consciences. If their impotence results from some sin, they obviously should deal with the problem by repenting and amending their lives.

The sexual activities of a married couple cannot be marital unless carried out as acts of marital love.107 That requires mutual consent; it is impossible for either spouse to compel the other, physically or psychologically, to participate in authentic marital sexual acts. Marital love also requires that, in both intercourse and the sexual activity leading up to it and following it, the couple seek, not pleasure alone, but the wider good of marital communion, in which pleasure, though an important element, is subordinate. Efforts to deal with impotence cannot be morally acceptable unless the behavior of both spouses expresses marital affection, is mutually agreeable, and is at least implicitly intended by both to serve the good of their marriage.

Moreover, sexual acts cannot be acts of marital love unless two conditions are met: (1) during them neither spouse deliberately entertains wishes that he or she were instead having intercourse with someone else, and (2) neither would be willing to engage in these activities if they were not with the spouse but adulterous. This consideration excludes not only individuals but couples from using pornography to try to overcome impotence, for either those doing this conditionally intend adultery or, at least, deliberately arouse themselves by means of the erotic appeal of someone other than their spouses. If that is not adultery in the heart—which I am inclined to think it is—it surely is an occasion of sin that one cannot rightly enter into.

All moralists faithful to the Church’s teaching agree that the intentional stimulation of either or both spouses to orgasm entirely apart from genital contact must be excluded as morally unacceptable. By involving orgasm, that behavior constitutes a sexual act complete in itself, yet one that cannot unite the couple in one flesh. A sexual act complete in itself cannot extend previous, or prepare for prospective, marital intercourse; an act that does not unite the couple in one flesh is not intercourse, and so cannot be marital intercourse. In fact, it is masturbation; and if mutual it is mutual masturbation. Thus, your view with regard to the first question in (4) is sound. I shall treat the other questions before returning to the second question in (4).

Many faithful moralists have discussed questions about the morality of a married couple’s sexual acts short of intercourse (see LCL, 641–42).108 Provided such activities are acts of marital love, in the sense already explained, and provided neither spouse intends or is likely to have an orgasm apart from intercourse, incomplete sexual acts, which lead to sexual arousal, are morally acceptable expressions of marital affection.109 For most married couples, such acts both bring about a continuing experience of one-flesh communion and prepare, at least indirectly and remotely, for eventual marital intercourse. Even for elderly couples who no longer have any prospect of intercourse, such incomplete sexual acts can be appropriate expressions of marital affection inasmuch as they continue to realize, to the extent possible, the one-flesh unity realized in previous acts of marital intercourse and to provide the couple with an experience, though imperfect, of their unity. So, your view with regard to (1) is sound: Even if there is no prospect that a married couple will again have intercourse, they may express their affection by means of mutually agreeable sexual activities that cause some sexual arousal and pleasure, provided neither intends or wrongly risks having an orgasm or seeks satisfaction by subsequent self-stimulation.

In many cases, a wife’s oral stimulation of her husband’s penis is morally unacceptable. Sometimes, either or both spouses intend this behavior to bring about ejaculation apart from intercourse. In that case, it is sodomy, and, as already explained, is morally excluded. Even when neither spouse has that wrongful intention, this behavior cannot carry out an act of marital love if the wife finds it repugnant, as many do. Nor can the behavior effectively serve as an incomplete act leading to marital intercourse if in fact it impedes intercourse by bringing about ejaculation apart from it, even if unintentionally.

However, sometimes the wife’s oral stimulation of the husband’s penis is no less natural than other affectionate kisses and touches that prepare for intercourse. That is so when it is intended by both spouses to be an incomplete sexual act leading to marital intercourse, is willingly done by the wife for that purpose, and serves the purpose effectively. And that is so with the couple in (2). Nor is there any moral problem in this husband’s manually stimulating his wife to orgasm immediately after intercourse, which is over too quickly to give her complete satisfaction. Unlike the husband’s orgasm, the wife’s need not occur during intercourse itself, since the time at which she is completely satisfied does not affect intercourse insofar as it is a reproductive function. So, since this stimulation continues that begun in intercourse, it can pertain to the couple’s marital act, which realizes their one-flesh communion and provides them with an experience of it.

My reply to question (3), about the constriction ring, is that using it can be morally acceptable. If any semen whatsoever reaches the wife’s vagina, the couple’s acts are authentic marital intercourse and will be virtuous, provided they are not morally defective in some other way. To see why this is so, it is necessary to understand the minimum requirements for marital intercourse considered as a reproductive-type human act.

Marital intercourse, as has been explained, is much more than a reproductive-type act, but it must at least be that if it is to make the couple two in one flesh and thereby allow them to experience themselves as one. For, among all sexual performances, only a reproductive-type act is a single function of a mated pair. Other sexual acts of a male and a female, even if they involve intimate genital contact, are really two separate and distinct sexual performances, and so must be excluded as nonmarital, even when engaged in by a married couple. It follows that marital intercourse must have both the intention and the outward behavior characteristic of a reproductive-type act.

For the act to be reproductive as to intention, the couple need not intend to reproduce. Other animals generally are inclined to mate only at fertile times, but humans’ inclination to mate is not so limited; yet, given the appropriate behavior and intention, such an act still is reproductive in kind. Two things are necessary with respect to intention: (1) there must not be an intention to impede conception—irrelevant here, since couples who know they are not fertile cannot have that intention—and (2) there must be the intention to carry out the appropriate behavior. Given the latter intention, the act, morally speaking, will be intercourse (and so, if marital, will be marital intercourse) even if the behavior unintentionally is defective, for example, if the man cannot reach orgasm.

The appropriate outward behavior for a typical reproductive-type human act is the same as in other mammals. The couple adjust their bodies so that the head of the male’s penis is inside the female’s vagina, and then move in a manner that causes the membrane covering the head of the penis to be stimulated until the male’s orgasm occurs, whereupon the penis becomes limp and intercourse naturally ends.

Various conditions prevent or impede subsequent stages of the normal reproductive process. For example, a woman might lack a uterus, either due to a birth defect or (more likely) a hysterectomy; a man who has had prostate surgery may have retrograde ejaculations (rather than being ejaculated normally from the penis, almost all the semen flows into the bladder and is voided when the man next urinates). But such conditions in no way affect the behavior essential to the human act, so knowing they exist does not prevent couples from engaging in human acts of sexual intercourse.110

The vacuum device and constriction ring are used to obtain and sustain the erection needed for sexual intercourse. Preventing normal ejaculation is an unintended side effect of the ring, and so its use would be consistent with the intention required for human sexual intercourse even if this couple were potentially fertile. The ring’s effect on ejaculation is no more drastic than the effect prostate surgery sometimes has. The behavior directly in the couple’s power, which brings about ejaculation, remains possible, and the couple engage in it. So, the act is an act of sexual intercourse. Being uncertain whether some ejaculate reaches the vagina, the couple, in my judgment, may assume that at least some does.

Someone might object that, if a younger couple believed they were fertile and wanted to have children, they would not deal with the husband’s impotence by using the constriction ring, which interferes with ejaculation, but would choose some method ensuring that all the ejaculate reached the vagina. So, the objection could conclude, the behavior of this elderly couple is not adequate for a reproductive-type act. The answer is twofold. First, the fertile couple no doubt would use some other method to overcome impotence if they could, but if they could not, they might well deal with it by using the vacuum device and constriction ring, hoping some semen would be ejaculated into the vagina. Second, even without penetration and ejaculation in the vagina, pregnancy can result if semen is deposited at the entrance to the vagina. So, a fertile couple using the constriction ring could increase the likelihood of conception by positioning themselves so that, when the husband removes the ring, the semen that flows from his penis falls into the entrance to the vagina.

An elderly couple using the device also can do that. Still, since I think the elderly couple who use the constriction ring meet the behavioral requirement for a reproductive-type act in having intercourse and may assume that some ejaculate reaches the vagina, I do not think that, in removing the ring, they need take the further step the fertile couple would take. However, they certainly may do so if that is conducive to their peace of conscience.

The preceding discussion suggests the answer to the second question in (4). If a couple make genital contact in which ejaculation occurs with the tip of the penis just within the entrance of the vagina, they meet the minimal behavioral conditions for a reproductive type act, and so for marital intercourse.111 As explained in answer to the second question, the husband may then stimulate the wife to orgasm.

105. Impotence means incapacity for sexual intercourse, usually due to a man’s inability to have or maintain an erection adequate for intercourse. Impotence is distinct from infertility—that is, the inability of a couple to have a baby. All postmenopausal women are infertile, but not all elderly men are impotent, let alone infertile.

106. They are dealt with amorally, however, by otherwise sound health care providers and counselors; see, e.g., Edward M. Brecher, Love, Sex, and Aging: A Consumers Union Report (Boston: Little, Brown, 1984).

107. The response given here condenses parts of the treatment of the sexual activities of married couples in LCL, 633–47.

108. A sound treatment of these matters, including the morality of oral-genital contacts preparatory to intercourse: John C. Ford, S.J., and Gerald Kelly, S.J., Contemporary Moral Theology, vol. 2, Marriage Questions (Westminster, Md.: Newman Press, 1964), 210–13, 224–34.

109. If marital sexual acts short of intercourse cause a spouse to have an accidental (unintended) orgasm apart from intercourse, that event is not in itself a human act, and so is not a sin. But unless a couple are attempting to engage in intercourse, for either spouse deliberately to take a significant risk of orgasm apart from intercourse is, in my judgment, either conditionally to intend nonmarital satisfaction or an occasion of that sin that should be avoided.

110. See Thomas J. O’Donnell, S.J., Medicine and Christian Morality, 2nd ed. rev. (New York: Alba House, 1991), 231–32, regarding retrograde ejaculation after prostate surgery; he supposes that a small amount of ejaculate probably reaches the vagina.

111. According to Canon Law, even if the husband is incapable of a normal erection, partial penetration of the vagina is sufficient for intercourse: see The Canon Law Society of Great Britain and Ireland in association with The Canadian Canon Law Society, The Canon Law: Letter and Spirit: A Practical Guide to the Code of Canon Law (Collegeville, Minn.: Liturgical Press, 1995), commentary on c. 1084, §§1–2.