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“Age brings changes at 70 just as at 17. But you never outgrow your need for intimate love and affection.”1
There is little medical literature concerning sexually transmitted infection in the elderly. The paucity of published information may reflect the low clinical workload this population generates within genitourinary medicine (GUM) services, but also suggests a more general lack of interest in the sexual health of elderly patients.
This degree of scientific neglect reflects the attitudes of medical practitioners and those of the patients themselves. The older generation may have grown up with the belief that sex was something improper or unmentionable. They are often uncomfortable sharing this aspect of their lives which, as a topic, may have been rarely discussed in the past with either peers or healthcare professionals. In direct contrast, the contemporary media project sex and sexuality in a way that encourages discussion and debate. Articles addressing modern sexuality emphasise appearance, fitness, and most predominantly youth. These articles are mostly written by, for, and about the young and tend to neglect issues relating in the same context to an elderly population.
To confound matters further, medical practitioners can be uneasy discussing a topic that is infrequently encountered in their clinical practice. The idea of a sexually active elderly person compels us to sexualise and consider the sexual needs of our own older relatives, including our parents. We are also then forced to project our own sexuality into the future and consider the accompanying physical and mental compromise.
When Johnson and colleagues published Sexual Attitudes and Lifestyles in 1994 the upper age limit for those surveyed was 59 years.2 The reason given for this limit was related to the measurement objectives of the survey. These included contraception, infertility, and unwanted pregnancy, all of which are of little personal concern to the elderly.
The elderly population’s lower risk of sexually transmitted infection directly relates to a number of factors including a tendency towards mutually monogamous relationships, and death or incapacity of spouse leading to reduced frequency of partnered sex.3 For example, in these data from the United States which included patients aged 18–89 years, the percentage of those who were sexually inactive by the age of 80 years was 50% for men and 95% for women.3 It is reasonable to think that these figures will be similar in other equally long lived populations. In addition, it is recognised that only 10% of patients with sexual dysfunction consult a doctor suggesting a substantial health problem among younger members of the population which is even greater among older people.3 When older people do present to GUM clinics it is often with multifactorial problems involving concurrent medical conditions, drug therapy, and psychosexual issues (see letter, p 379). Erectile failure is generally accepted to be one of the commoner dysfunctions. This assumption is strengthened by the current demand for the new clinically effective oral medication for erectile failure.4 This product may increase sexual activity and possible sexually transmitted infection risk in a previously inactive population; those who may be consulted by these patients should be prepared for a change in their demands and diseases. Treatment for other conditions, however, may be medically suboptimal when patients’ own perceptions and wishes for therapy conflict with those of their doctors. This is seen particularly in genital malignancy when issues relating to quality and length of life arise.5
The elderly population is not generally considered at risk of HIV infection. One author describes the stereotypic elderly individual as a “heterosexual, monogamous, drug-free grandparent”.6 This is clearly not the case in Florida, as reported by Nadler et al, who reviewed all HIV related medical admissions over 60 years of age in two veterans’ hospitals over a 1 year period. They found 50% of such patients were in conventional high risk categories.6 Furthermore, El-Sadr and Gettler found an HIV antibody prevalence of 5% in a retrospective analysis of all admissions over 60 years of age to a New York State hospital in patients who were not previously known to be HIV seropositive.7 It is important that the complications of HIV infection are considered in the differential diagnosis of disease presentation in the elderly, especially as the natural history of HIV infection in this population is characterised by a more rapid progression and shortened survival after an AIDS diagnosis.8
A proportion of older people are sexually active and at risk of acquiring sexually transmitted and other lower genital tract disease. Information on the topic of sexual health should not exclude the elderly either by its availability or presentation. A sensitive approach to targeting information via agencies frequently used by this population may help to inform the population, destigmatise the topic, and facilitate GUM service attendance. Specialist clinics should be easily accessible to the elderly and be perceived as welcoming, and capable of managing the sexual health needs of the elderly population.
Only by encouraging the elderly population to access GUM services may important epidemiological questions relating to their sexual behaviour be asked and information subsequently used to develop public health strategies.