Successful sexual aging: A narrative review using the multidimensional theoretical paradigm of systems sexology to explore sexual health in midlife and older adults

Purpose: Global population aging is shifting healthcare priorities from merely extending life to enhancing quality of life, yet sexuality remains a neglected dimension of healthy aging. Prevailing approaches focus on discrete sexual dysfunctions such as erectile dysfunction, menopause-related dyspareunia, or late-onset hypogonadism, overlooking the multidimensional and dyadic nature of sexual aging. This review reframes successful sexual aging (SSA) as a biopsychosocial process evaluated in the light of the new systems sexology, integrating decline and adaptation, and introducing the paradigm of SSA grounded in acceptance, adaptation, and activation. Methods: We conducted a narrative review of literature across sexual medicine, geriatrics, endocrinology, urology, gynecology, psychiatric, psychology, sociology, and regenerative medicine. We critically examined central theoretical constructs of CouplePause and DoublePause along with validated assessment instruments and a proposed conceptual framework, the Sexual Aging Index (SAI), intended to guide future multidimensional assessment of sexual aging. Evidence synthesized from gender-specific and cross-cultural perspectives illuminated key conceptual voids, translational barriers, and novel opportunities to advance the field of sexual aging research. Results: Sexual aging is shaped by endocrine decline, neurovascular changes, psychological resilience, sociocultural norms, and relational dynamics. Men commonly experience gradual androgen and vascular decline, while women face abrupt transitions linked to menopause and genitourinary syndrome of menopause (GSM), yet both trajectories are strongly moderated by adaptation and couple dynamics. Current assessment instruments fail to adequately capture aging-specific, dyadic dimensions, highlighting the need for multidimensional tools like the SAI. Interventions extend beyond pharmacology to include translational Chinese medicine (TCM), functional nutrition, low intensity extracorporeal shock wave therapy (Li-ESWT), platelet-rich plasm (PRP), stem cell therapies, and vaginal energy-based devices, though evidence remains heterogeneous. The SSA framework reframes it as a positive, process-oriented phenomenon linked to quality of life and relational health, while challenging sexual ageism at individual, clinical, and policy levels. Conclusions: Sexual aging represents an emerging frontier in sexual medicine, demanding a shift from deficit-based models to an integrative, couple-centered, and culturally inclusive paradigm. Advancing this field will require international consensus on definitions and frameworks, the development of validated multidimensional assessment tools, the implementation of rigorous multimodal clinical trials, and societal initiatives to dismantle sexual ageism. Embedding sexual health into healthy aging policies, healthcare delivery, and medical education will be critical to ensure that intimacy, dignity, and sexual vitality remain integral to longevity in the twenty-first century.