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The message that senescence is largely under personal and social control is comforting, but we must recognize that some effects of aging are inevitable. Bodies and minds are not the same at 65 as they were at 25. Always remember, however, that every period of life is multi-directional. The adult’s task is not to deny changes but to put them into perspective so that joys increase even as aging does.

One of the obvious changes is appearance. Adults look older every decade.

SKIN AND HAIR The first visible signs of aging are in the skin, which becomes dryer and rougher. Collagen, the main component of the connective tissue of the body, decreases by about 1 percent per year, starting at age 20. By age 30, wrinkles become visible, particularly around the eyes. Diet has an effect—fat slows down wrinkling—but aging is apparent in every layer of the skin (Nagata et al., 2010).

Especially on the face (most exposed to sun, rain, heat, cold, and pollution), skin becomes less firm. By middle adulthood, age spots, tiny blood vessels, and other imperfections are visible in people who work outside (usually men), and troubling to people (usually women) who associate youth with sexual attractiveness.

Hair becomes gray and thin, first at the temples by age 40 and then over the rest of the scalp. Many men experience “male pattern baldness.” Appearance changes do not affect health, but they signify age, so adults spend money and time coloring, thickening, and styling.

SHAPE AND AGILITY The body changes shape between ages 25 and 65. A “middle-age spread” increases waist circumference; pockets of fat settle on the abdomen, the upper arms, the buttocks, and the chin; people do not stand as straight and tall as they once did (Whitbourne & Whitbourne, 2011).

By late middle age, adults are shorter, because back muscles, connective tissue, and bones lose density, making the vertebrae shrink. People lose about an inch (2 to 3 centimeters) by age 65. The loss is in the spine, not the leg bones, another reason that waists widen.

Muscles atrophy; joints lose flexibility; stiffness appears; bending is harder; balance more difficult. Rising from sitting, twisting in a dance, hoping on one foot, or even walking “with a spring in your step” is not as easy. A strained back, neck, or other body part may occur.

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The aging of the body is most evident in sports that require strength, agility, and speed: Gymnasts, boxers, and basketball players are among the athletes who benefit from youth but who experience slowdowns by age 20.

These physiological changes seem clearly to be losses, but remember that adulthood may bring intellectual and emotional gains. In fact, some 30-year-olds are more valuable teammates than younger athletes, and many of the best coaches are over age 50. A gain occurs if people learn to value character, not appearance.

From childhood on, each person’s routines and habits powerfully affect every disease and chronic condition. This is particularly true for problems associated with aging—from arthritis to varicose veins—that may first appear after age 50 but begin decades before. Indeed, some adult conditions are affected by maternal health when that person was an embryo (Haase et al., 2013). Habits before age 30 affect health after age 60.

Cancer (by far the most common cause of adult death before age 65) is a classic example. Most cancers are affected by the health habits just described that increase allostatic load. Pollution and neighborhood stress add to the problem. Genes are important as well—about a fourth of all breast cancers are related to two particular alleles (BRCA1 and 2), and several other alleles increase the risk (Kean, 2014), but genes alone rarely cause cancer without some environmental trigger.

ATTITUDE AND DISEASE Adults can stop abusing drugs, improve nutrition, and exercise regularly. They can decide to be screened and treated, or not. These actions postpone many diseases, and older adults are more likely to do them (Reyna et al., 2015).

Surprisingly, cancer survivors (estimated at 14.5 million people in the United States) are likely to become healthier after their illness. In the first year after treatment ends, many fear cancer’s return, experience less vitality or memory, and are depressed by reduced support. But then millions live decades after diagnosis, and “self-reported benefits include strengthened interpersonal relationships, commitment to life priorities, life appreciation, personal regard, spirituality, and attention to health behaviors” (Stanton et al., 2015, p. 165).

Although aging brings infirmities, injuries, and diseases, that may have a bright side. A popular 2013 song repeated the folk saying “what doesn’t kill you makes you stronger.” The hope is that each challenge that is overcome increases a trait called hardiness, an attitude that promotes learning from stress (Maddi, 2013).

Let us not be too sanguine. Stresses accumulate, and coping is not easy, as explained later in this chapter. Each illness makes another more likely, and chronic disease burdens adults with daily hassles. Many researchers believe that it is neither helpful nor proven to imply that attitude is a major cause of disease or recovery (Green McDonald et al., 2015).

Finding the right balance between hope and despair in explaining the connections between disease and attitude is not simple. Nonetheless, all the researchers agree that rates of disease and opportunities for growth both increase in adulthood.

SES, IMMIGRATION, AND HEALTH Money, education, and intelligence protect health. This is true among nations when only overall health is tallied, as well as when the focus is on each specific disease.

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Using life itself to indicate health, people in the richest nations (e.g., Japan) live 25 years longer than those in the poorest ones (e.g., Sierra Leone) (see Figure 12.4). Or, to pick one non-fatal disease, rheumatoid arthritis (which typically occurs in mid-adulthood, unlike osteoarthritis) is more common internationally as income falls (Putrik et al., 2015).

SES differences are apparent within every nation as well. For example, in the United States, adults (age 25) with a college degree live an average of nine years longer than those with no high school diploma (National Center for Health Statistics, 2012). [Level of education is often used as a proxy for income, as it correlates closely.] Recent data find the SES gap widening in the United States, and health disparities follow (Olshansky et al., 2012).

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It is not obvious why the connection between SES and health is so strong. Does education teach better health habits? Does income allow better medical care? Do advantages cascade, such as childhood stimulation and family SES leading to college, and then degrees leading to better jobs and neighborhoods with less pollution and more places to walk, bike, and play? Do intelligent people eat better? Do wealthy people avoid stress by hiring other people to do the work they do not want to do?

Before settling on any of these explanations, consider a conundrum first explained in Chapter 2: Immigrants are usually healthier yet poorer than the native-born of the same ethnicity. Paradoxically, they have less heart disease, drug abuse, obesity, and birth complications (García Coll & Marks, 2012). In the United States, children and grandchildren of immigrants surpass their elders in education, income, and English fluency—but as SES rises over the generations, so does virtually every illness.

Many explanations have been offered for the immigrant paradox. Perhaps healthy people are more likely to emigrate. Then their good health protects them despite their poverty. However, the data find that this “healthy migrant” theory is not sufficient to explain immigrant health (Bates et al., 2008; García Coll & Marks, 2012). From a developmental perspective, the most plausible explanation is social support, often very strong in new immigrant families and proven to protect health from cradle to grave (Priest & Woods, 2015).

Another adult set of gains and losses occur with sexuality. Arousal, orgasm, and fertility are all affected by age.

SEXUAL RESPONSIVENESS Sexual arousal occurs more slowly and orgasm takes longer with senescence. However, some say that sexual responses improve with age. Could that be? Might familiarity with one’s own body and with that of one’s partner make slower response more often a joy than an anxiety?

A U.S. study of women aged 40 and older found that sexual activity decreased each decade but that sexual satisfaction did not (Trompeter et al., 2012). A British study of more than 2,000 adults in their 50s found that almost all of them were sexually active (94 percent of the men and 76 percent of the women) and, again, that most were quite satisfied with their sex lives (D. Lee et al., 2015).

INFERTILITY Although sexual satisfaction may not decline with age, reproduction certainly does. Rates of infertility (often defined as failure to conceive after a year of trying) vary from nation to nation, primarily because the rate increases when medical care is scarce (Gurunath et al., 2011).

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Age matters as well. In the United States, about 12 percent of all adult couples are infertile, partly because many postpone childbearing. Peak fertility is at about age 18.

If couples in their 40s try to conceive, about half fail and the other half risk various complications. Of course, risk is not reality: In 2011 in the United States, 116,000 babies were born to women age 40 and older, the only age group for whom the birth rate is steadily rising (Hamilton et al., 2012). Most of their babies become healthy, well-loved children.

When couples are infertile, either or both partners may be the problem. A common reason for male infertility is low sperm count. Conception is most likely if a man ejaculates more than 20 million sperm per milliliter of semen, two-thirds of them mobile and viable, because each sperm’s journey to the ovum is aided by millions of fellow travelers.

Depending on the man’s age, each day about 100 million sperm reach maturity after a developmental process that lasts about 75 days. Anything that impairs body functioning over those 75 days (e.g., fever, radiation, drugs, time in a sauna, stress, environmental toxins, alcohol, cigarettes) reduces sperm number, shape, and motility (activity), making conception less likely. Sedentary behavior, perhaps particularly watching television, also correlates with lower sperm count (Gaskins et al., 2013).

As with men, women’s fertility is affected by anything that impairs physical functioning—including disease, smoking, extreme dieting, and obesity. Many infertile women do not realize they have contracted one specific disease that impairs fertility—pelvic inflammatory disease (PID). PID creates scar tissue that may block the fallopian tubes, preventing sperm from reaching an ovum (Brunham et al., 2015).

ASSISTED REPRODUCTION In the past 50 years, medical advances have solved about half of all fertility problems. Surgery repairs reproductive systems, and assisted reproductive technology (ART) overcomes obstacles such as a low sperm count and blocked fallopian tubes. ART, especially IVF (in vitro fertilization), has led to an estimated 5 million births (Fisher & Giudice, 2013).

IVF is quite different from the typical conception. The woman must take hormones to increase the number of fully developed ova, and the man must ejaculate into a receptacle. Then surgeons remove several ova from one or both ovaries and technicians combine the ova and sperm in a laboratory dish, often inserting one active sperm into each normal ovum.

Success is evident a few hours later, as several zygotes form and duplicate. Then one or more healthy blastocysts are inserted into the uterus, which is ready for implantation via additional drugs. Everyone waits and hopes.

Even with careful preparation, fewer than half of the inserted blastocysts successfully implant and grow to become newborns. Age of the ova is one crucial factor, so some young women freeze their ova for IVF years later (Mac Dougall et al., 2013). Miscarriages (perhaps one in three implanted embryos) increase with age.

If IVF newborns are normal weight, they do as well or better than other babies, not only in childhood health, intelligence, and school achievement but also in self-reported emotional development as teenagers (Wagenaar et al., 2011). One reason is that their parents tend to be more responsive. A study in Jamaica found that IVF parents are more authoritative, less permissive or authoritarian, than other parents (Pottinger & Palmer, 2013).

IVF children may grow well because they are planned and wanted. Of course, planning itself is cultural and contextual. National policy and culture have an effect, and traditionally, men tend to want more children than women do, although each half of a couple is affected by the fertility hopes of the other (Billingsley & Ferrarini, 2014), The availability of contraception affects planning, but even when birth control is available and free, estimating how many pregnancies are planned is complex.

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For instance, more than 8,000 parents in France were asked whether each pregnancy was planned, unplanned (mistimed), or unwanted. Half of them were asked that simple question. The answers were: 39 percent planned, 34 percent mistimed, and 27 percent unwanted. The other half were first asked whether they had been using contraception at conception. That made 55 percent say they planned the pregnancy: 24 percent said it was mistimed and 21 percent unwanted (Moreau et al., 2014) (see Figure 12.5).

MENOPAUSE During adulthood, the level of sex hormones circulating in the bloodstream declines—suddenly in women, gradually in men. As a result, sexual desire, frequency of intercourse, and odds of reproduction decrease. The specifics differ for women and men.

For women, sometime between ages 42 and 58 (the average age is 51), ovulation and menstruation stop because of a marked drop in production of several hormones. This is menopause. The precise age is affected primarily by genes (17 have been identified) (Morris et al., 2011; Stolk et al., 2012) but also by smoking (earlier menopause) and exercise (later).

In the United States, one in four women has a hysterectomy (surgical removal of the uterus), which may include removal of her ovaries. If she was premenopausal, removal of ovaries causes vaginal dryness and body temperature disturbance, including hot flashes (feeling hot), hot flushes (looking hot), and cold sweats (feeling chilled).

Natural menopause produces the same symptoms, but not as suddenly and not in everyone. Early menopause, surgical or not, increases the risk of health problems later on (Hunter, 2012).

The psychological consequences of menopause vary more than the physiological ones. Some menopausal women have erratic moods, others are more energetic, and still others become depressed (Judd et al., 2012). Many women are relieved that menstruation and fear of pregnancy have ended. Margaret Mead (famous anthropologist who studied women throughout the world) felt renewed energy after age 50 and called it “post-menopausal zest” (Mark, 1999, p. 51).

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Do men undergo anything like menopause? Some say yes, suggesting that the word andropause should be used to signify age-related reduction in testosterone, which reduces sexual desire, erections, and muscle mass (Samaras et al., 2012). Even with erection-inducing drugs such as Viagra and Levitra, sexual desire and speed of orgasm decline with age, as do many other physiological and cognitive functions.

But most experts think that the term andropause (or male menopause) is misleading because it implies a sudden drop in reproductive ability or hormones. Some men produce viable sperm and hence become new fathers at age 80 or older. Sexual inactivity and anxiety can reduce testosterone—superficially similar to menopause but with a psychological, not physiological, cause.

To combat the symptoms of the natural decline in estrogen or testosterone, some adults have turned to hormone replacement. Most physicians are wary, citing correlations between artificial hormones and breast cancer in women and heart disease in men (Zbuk & Anand, 2012; Handelsman, 2011). Nonetheless, hormones are sometimes prescribed (Samaras et al., 2012; Panay et al., 2013; Giannoulis et al., 2013). All physicians agree, however, that adult health depends more on habits than on hormones.

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