Sexually Transmitted Diseases in the Elderly

“Lets discuss sexually transmitted diseases” is a phrase that’s not welcomed with open arms by many people. “Lets talk about sexually transmitted diseases in elders” makes the first phrase sound like a better option. And yet, that is exactly what must be discussed. As much as many people would like to avoid the topic, elderly adults have sex and contract sexually transmitted diseases just like younger adults. The difference is in awareness and education about STD’s. Young adults are asked frequently about getting tested for STD’s and receive information on safe sex practices. Elderly adults are often forgotten when it comes to safer sex education and may not be asked if they want to be tested for STD’s, have a sexual history taken, or be provided information on safer sex when meeting with medical providers (7). STD’s have an impact on the fragile health of the elderly and rising rates of STD’s in this population must be reduced to ensure the health of elderly adults. Broader implementation of safer sex education and testing for STD’s aimed at the elderly population is a necessary step to ensure better health.

It’s a common misconception that the elderly population doesn’t participate in sexual activities. In a study of sexuality among older adults in the U.S., 54 % of respondents in the age group 75 to 85 years old were found to engage in sex at least two to three times per month, and 31% reported engaging in oral sex (2). The National Social Life, Health and Aging Project survey found that about 75% of people in the ages 57 to 64, over 50% of people ages 65 to 74, and more than 25% of people ages 75 to 85 reported being sexually active (4). Many elderly people are sexually active and are at as much risk as any other age group for sexually transmitted diseases.

While the largest amount of people infected with sexually transmitted diseases are younger, its concerning that rates are rising in elderly people. U.S. News reported that the rates for herpes simplex, gonorrhea, syphilis, and chlamydia rose 23 percent in patients over the age of 60 from 2014 to 2018 (1). In 2018, the Centers for Disease Control and Prevention reported 539.9 cases of Chlamydia, 179.1 cases of Gonorrhea, and 10 cases of Syphilis in persons aged 65 and over per 100,000 people (3). Immunosenescence is change in the immune system associated with age. A higher mortality rate in the elderly is associated with changes in the aging immune system, which accumulate and lead to decreased ability to respond to infection (5). Rising rates of infection and deterioration of the immune system pose a great danger to the elderly when infected with STD’s. Though screening guidelines don’t require Pap smears in women over 65, a sexual health history is still an important tool to utilize in the care of older patients and must not be forgotten simply because of the patients age (9). A large issue contributing to rising rates of STD’s is that sex is such an uncomfortable topic to discuss with medical providers. A 2016 study found that older people feel reluctant to discuss sexuality in the healthcare setting, and women are especially hesitant to initiate a discussion about their sexual health. The study also found that older people feel that medical providers aren’t interested in their sexual health (8).

Risky behavior is a large contributor to transmission of STD’s and it does not seem to decrease with age. A study about condom attitudes of 899 men aged 45 to 74 revealed that 60% of respondents agreed that a condom is “not necessary when you are with the same person for a long time,” and 54% agreed that a condom “is not necessary when you know enough about the person to trust her/his word about her/his past.” While 62% of respondents agreed that they are concerned about catching an STD, 70% stated that they dislike condoms due to decreased sensitivity during sex and 52% agreed that condoms are a hassle to use (6). While trust and comfort play a large role in sexual activity, attitudes toward condom use in this group of older adults is concerning. More than half of the respondents agreed with views associated with risky behavior that may lead to transmission of STD’S.

With the population of baby boomers increasing, there are more people than ever residing in long term care facilities such as nursing homes and assisted living. These facilities prioritize caring for patients in regard to chronic diseases, fall prevention, and activities of daily living, but they appear to be failing at caring for resident’s sexual health. Residents of long term care facilities are concerned with sexual activities and studies have shown that staff at these facilities are unaware of residents views on this matter, indicating need for training and encouragement to initiate discussions with residents (10).

The overwhelming issue with STD’s in elderly populations appears to be lack of education about safe sex practice and STD’s, and lack of inquiry into the sexual health of elderly patients on part of medical providers. Instituting mandatory training for long term care staff is essential due to so many elderly patients residing in long term care facilities while engaging in sexual activity. Staff of these facilities get to know residents very well simply due to spending so much time with the same patients and caring for them every day. In this setting, feeling uncomfortable may not be an issue due to closer and more trusting relationships between caregivers and residents, so education for staff on the risks of STD’s and how to speak to patients about sexual health could ensure better outcomes. Occupational therapists are especially essential to opening up conversation about sexual health in this setting as they are the members of staff that help residents with intimate tasks such as bathing and dressing and could provide residents with most comfort to speak about their sexual health. Sexual health and practices should be discussed at initial admission to help curate a plan for the patient just as medications, therapy, and activities are planned (10). While open communication and addressing sexual health would improve caring for elderly patients in long term care facilities, privacy could become an issue. These facilities rely on multi-disciplinary care, including doctors, nurses, occupational and physical therapists, and many other staff members that the patient may not want to share details of their sexual activity with. However, providing a multi-disciplinary approach to sexual health would be in the best interest of the patient, so this approach may contradict itself in the battle between sexual health and privacy.

Primary care physicians and other individual medical providers do not face the issue of privacy as they treat their patients in a one-on-one setting. Implementing expanded sexual health education and assessments at routine medical appointments may be the optimal solution in this case. Many providers already have a trusting relationship with their patients but need to understand that inquiring into their elderly patients sexual health is as important as assessing chronic conditions. Training in the types of questions to ask and how to approach this topic may make providers more comfortable in initiating the conversation and more prone to assess for STD’s. Educating elderly patients on the risks of STD’s despite zero risk of pregnancy is imperative as patients may not understand that they are still at risk for infection (9). Proper condom use and the ways in which different infections are transmitted should also be discussed. Casually including the effects of STD’s while discussing diseases commonly affecting the elderly about may open up the door for further conversation. Mostly, providers need to understand that inquiring into their patients sexual activity is of utmost importance to ensuring health, no matter the age of the patient. It’s the providers responsibility to at least try to discuss sexual health with elderly patients and provide as much information and resources as the patient is open to receiving. The downfall to this approach is that there is no perfect way to assess if providers are truly inquiring into elderly patients sexual health and performing appropriate assessments and screenings for STD’s. While training may encourage providers to inquire more about elderly patients sexual health, ultimately it’s the providers responsibility to care for patients in the best way they can.

 

1. Howley, Elaine K. “What to Know About Rising STD Rates Among Seniors.” S. News & World Report. U.S News & World Report LLC. 10 Dec. 2018. https://health.usnews.com/health-care/patient-advice/articles/2018-12-10/what-to-know-about-rising-std-rates-among-seniors
2. Tessler Lindau, Stacy, et al. “A Study of Sexuality and Health Among Older Adults in the United States.” New England Journal of Medicine, vol. 357, 2007, pp. 762-774, doi: 10.1056/NEJMoa067423. https://www.nejm.org/doi/full/10.1056/NEJMoa067423
3. “Sexually Transmitted Disease Surveillance 2018.” Centers for Disease Control and Prevention, S. Department of Health and Human Services, 30 July, 2019. https://www.cdc.gov/std/stats18/toc.htm
4. “Older Adults and Sexual Health: A Guide for Aging Services Providers.” New York State Department of Health, New York State Department of Health, https://www.health.ny.gov/diseases/aids/general/publications/docs/sexual_health_older_adults.pdf
5. Aw, Danielle et al. “Immunosenescence: emerging challenges for an ageing population.” Immunology 120,4 (2007): 435-46. doi:10.1111/j.1365-2567.2007.02555.x
6. Garcia Jones, Sande et al. “Condom Attitudes of Heterosexual Men Ages 50 and Older Using Prescribed Drugs to Treat Erectile Dysfunction.” American Journal of Men’s Health, vol. 7, 2013, pp. 504-515, doi: 10.1177/1557988313486172. https://journals.sagepub.com/doi/pdf/10.1177/1557988313486172
7. Ports, Katie A et al. “Sexual health discussions with older adult patients during periodic health exams.” The journal of sexual medicine 11,4 (2014): 901-908. doi:10.1111/jsm.12448
8. Bauer, Michael et al. “Let’s talk about sex: older people’s views on the recognition of sexuality and sexual health in the health-care setting.” Health expectations : an international journal of public participation in health care and health policy 19,6 (2016): 1237-1250. doi:10.1111/hex.12418
9. Thomason, Ayasha et al. “Factors Affecting Gynecologic and Sexual Assessment in Older Women: A Lesson for Primary Care Providers.” Healthcare (Basel, Switzerland) 3,3 683-94. 11 Aug. 2015, doi:10.3390/healthcare3030683
10. Lichtenberg, Peter A. “Sexuality and physical intimacy in long-term care.” Occupational therapy in health care 28,1 (2014): 42-50. doi:10.3109/07380577.2013.865858