Human sexuality is beginning to be recognized by both doctors and policymakers as an important part of people's health. In his 2001 report, Surgeon General David Satcher stated that: "Sexuality is an integral part of human life ... inextricably bound to both physical and mental health. ... Sexual health is not limited to the absence of disease or dysfunction, nor is its importance confined to just the reproductive years."
But despite this governmental recognition, and the aging of the U.S. population, research in the field of geriatric sexuality has been largely overlooked. Only one large study that explores sexuality in older men and women in the U.S. has been completed: the 2005-06 National Social Life, Health and Aging Project (NSHAP). It enrolled over 3,000 men and women, aged 57 to 85. They were about half male and half female, and completed a face-to-face questionnaire covering the social, psychological, and health aspects of their lives. Detailed information about their sexual relationships, activity, and functioning was gathered and analyzed.
Sex and the Older Adult
NSHAP's findings highlight both the importance of a healthy sex life and the social settings in which people engage in sexual activities. Those who reported their health status as "poor" were less likely to be sexually active. Those who were sexually active and in poor health were more likely to report sexual problems. The data also showed that the quality of, and interest in, sex was associated with good health.
The study also found that sexuality in later life takes place, for the most part, within a long-term marital relationship. Men are considerably more likely than women to have a partner later in life; thus much of their aging is done in the company of a partner. This may be due to the fact that men are often married to younger women, and that women often live longer than men. A man's sexual relationship also tends to be more fulfilling than a woman's because he has a partner, despite health difficulties that come with old age. Women, on the other hand, are more likely to experience aging, health problems, and death alone. Without a committed partner, many women do not have sex, which helps to explain the differences between the sexual activities of older men and women.
Sexual activity among older adults declined with age: 73% of people aged 57 to 64 were active, 53% of those aged 65 to 74 were active, and only 26% of those aged 75 to 85 were active. About half of the men and women who reported sexual activity also reported at least one sexual problem. The most common female sexual problems were: low desire (43%), difficulty with vaginal lubrication (39%), and inability to climax (34%). For men they were: erectile difficulties (37%), lack of interest in sex (28%), and anxiety about performance (27%). About 14% of men reported using medication or supplements in order to improve sexual functioning, as these medications are readily available. Proven interventions for female sexual problems are not widely available, and much less attention has been paid to older female sexuality.
STIs and the Older Adult
Although the amount of sex people were having decreased, they still experienced sexually transmitted infections. Genital herpes and HPV are the most common infections among older women. Genital herpes prevalence among men and women over 70 was 28%, and the rate was higher in women than in men. Chlamydia, gonorrhea, and syphilis cases occured in less than 1% of older women, but the percentage is likely an underestimate due to the lack of a uniform tracking system and STIs being overlooked by doctors. High-risk HPV, an important factor in cervical cancer and dysplasia, was found in 6% of the women. Cervical cancer is one of the leading causes of female cancer deaths, and 20% of cases occur in women over 65. Many of the screening and prevention practices for cervical cancer, including the HPV vaccine, have age-based criteria that exclude older women.
While some of these STIs were contracted in later life, many of the infections likely occurred earlier and have either stayed dormant or persisted through the years. In a recent study of women aged 67 to 99, however, 1% were diagnosed with an STI during the nine years of the study, highlighting the fact that older women are still very much at risk for new STIs. Further complicating the diagnosis of STIs in older women is the fact that many can produce symptoms similar to those experienced by postmenopausal women. For example, chlamydia and gonorrhea can present as pelvic pain and pain during intercourse, problems often encountered in older women.
A recent multinational survey of people 40 to 80 years old also showed that women were more likely than men to rate sex as an unimportant part of life and to report lack of pleasure with sex. Despite similarly high rates of sexual problems among women and men, women were less likely than men to discuss sex with a physician, either out of embarrassment or because of societal norms, and doctors may not talk to their older patients about sex due to preconceived notions about sexuality at their age. This can compound the issue of STIs among older adults, especially women.
HIV and Older Adults
The majority of new HIV cases in the U.S. occur among people under 50. 10% of new HIV infections in the U.S. occur in people over 50, although this number is as high as 17% in some areas. Almost a third of these new infections are among older women, particularly within minority racial and ethnic groups. The likelihood of receiving an HIV and AIDS diagnosis at the same time increases with age. The CDC estimates that by 2015, half of all people with HIV in the U.S. will be over 50, and that more than a third will be women. The longer survival of people diagnosed earlier in life also accounts for the increasing number of older adults with HIV.
Many HIV prevention messages target the younger population, and counseling and testing is rarely offered to older adults by their physicians. STI prevention strategies have not been well tested among older adults, and few older women report using condoms. With relationship changes later in life, new sexual encounters are not uncommon for older men and women who have experienced divorce or death of a partner. While younger women use condoms for pregnancy prevention, this motivation is not present in women who are past childbearing age. Condoms should be applied when the penis is fully erect, but some older men do not reach full erection until after sex is initiated. Water-based lubricants can be used to combat vaginal dryness and friction. Any questions about the use of any product, or general questions about sexual activity, should be directed to a physician or other provider knowledgeable in older adult sexuality.
Sexual problems experienced in older adults may increase the risk of contracting an STI, especially in women. Vaginal dryness and thinning of the vaginal walls can create a hospitable environment for the transmission of some STIs, as the tissues in the vagina can easily become inflamed during sex. Also, with the emergence of medications to treat male erectile dysfunction, such as Viagra, many older men are able to experience an extended sexual life, but may not have received the prevention messages needed to protect themselves and their partners.
Lack of Communication
Although they have largely been ignored in terms of sexuality research, older adults are sexually active. They deal with many problems ranging from lack of interest in sex to discomfort during it. Many of these issues could easily be dealt with by physicians, but a lack of communication and knowledge makes many feel helpless. The topic of geriatric sexuality would greatly benefit from more attention from both researchers and clinicians, if only to improve the quality of life of older adults.
In one study, adults over 65, physicians, and nurses were asked about their knowledge of safer sex and HIV risk. The results show a great discrepancy in the understanding of HIV transmission among older adults on the part of both patients and providers. Many older adults were quite aware of the term "safe sex," noting the use of condoms and utilizing the term "protection." Older adults were also very aware of the risk of getting HIV; more than half of the 20 respondents who underwent in-depth interviewing expressed moderate to extreme concern about HIV. This was in great contrast to the ideals and perceptions of the physicians and nurse-practitioners, among whom only about 6 out of 20 expressed concern of HIV risk among their older patients.
Barriers to communication between older adults and their physicians about HIV risk also exist. In the above study, physicians and nurse-practitioners listed lack of time during a patient visit, more pressing medical issues, trying not to embarrass the patient, and just assuming that they are not sexually active due to their age as reasons they do not talk to their older patients about HIV. The patients interviewed also made the point that they would be open to these discussions, but they would not bring the issue up themselves. This is a very important gap to address as it often results in a missed opportunity to counsel and treat older adults in a clinical setting.
The NSHAP study debunks the conventional wisdom about a sexless old age. Adults continue to be sexually active late into life, especially those with a spouse or long-term partner. And although older men are more sexually active, this is largely due to the lack of partners available to older women. We need to change our thinking about what it means to age successfully and to embrace the idea that human beings are sexual beings throughout their lives. Part of this involves outreach and education to physicians who care for older adults to make them aware that the topic of sexuality and sexual health is just as important to address in clinical settings as other health issues.
The study also underscores the need for STI education and prevention efforts in our older population. STIs are prevalent in this group, and older adults who are unaware of this issue are at risk for infection or for infecting others with STIs such as HIV. While adults over 50 currently account for 10% of new HIV infections, this proportion will surely grow if we do not give them the information they need to keep themselves healthy. Prevention efforts targeted at older adults could ensure that this rate of infection remains stable or even decreases. Part of this effort involves changing the CDC testing guidelines for HIV to include people of all ages, not only those aged 13 to 64. The fact that Medicare will now reimburse HIV testing for those over 64 is an important step in the right direction.
Lastly, the NSAHP should be replicated on the older LGBT population. Sexuality in later life takes place, for the most part, within long-term marital relationships. Such long-term relationships are not a dominant characteristic within LGBT communities. This may affect the sexuality and health of those too-often marginalized communities. Similarly, NSHAP should be conducted in other countries to determine whether the patterns seen in older U.S. adults are similar to or different from older adults in cultures around the world.
Adapted from: "Sexuality, Sexual Function, and the Aging Woman" by Stacy T. Lindau, M.D., M.A.P.P., in Hazzard's Geriatric Medicine & Gerontology, Sixth Edition (2009).
Katherine Githens is a research assistant working on sexual health projects in Dr. Lindau's research lab. Emily Abramsohn is a Research Core Coordinator at the University of Chicago Medical Center.