Our culture has a lot of taboos around sex and the body, and a big one revolves around older adults having sex. Many people just assume that when you hit a certain age, sex becomes a thing of the past. But as many an older American can attest, that’s simply not true. Many older adults remain sexually active and have a great time being so. However, for some, it could lead to health problems.
That’s because across the board and among all ages, STDs are on the rise in America. According to a 2018 report from the Centers for Disease Control and Prevention, in 2017, nearly 2.3 million cases of chlamydia, gonorrhea and syphilis were reported in the United States. That’s the highest number ever recorded for these diseases.
Particularly among older adults, the climb in STD rates appears steeper. A recent analysis of patients on athenahealth’s network found that patients over age 60 account for the biggest increase of in-office treatments for sexually transmitted infections. The report found that in adults over age 60 diagnosis rates for herpes simplex, gonorrhea, syphilis, hepatitis B, trichomoniasis and chlamydia rose 23 percent between 2014 and 2017. (HIV was not included in this analysis.) That’s compared to an 11 percent increase among the entire population over age 13.
Dr. Stacy Lindau, professor of obstetrics and gynecology and medicine-geriatrics at the University of Chicago and director of the program in integrative sexual medicine at WomanLab, a public-access website covering women and sex in the context of aging and illness, says that while there does appear to be an increase — likely driven by several factors — it’s important to keep these figures in perspective. “Although it appears that there’s an increase in rates, the rates (of sexually transmitted infections among older adults) are still exceedingly low.”
Dr. Janet Pregler, director of the Iris Cantor — UCLA Women’s Health Center, agrees, noting that “the heaviest burden of STIs is in younger people, and because of that, we haven’t tracked or studied this in older adults effectively at all.” So while the availability of hard data surrounding exactly what’s going on with older adults and STIs is limited, there does appear to be an uptick of diagnoses among older adults.
The increase is “more prevalent in men than women, and especially with men having sex with men,” says Dr. Lisa Granville, professor of geriatrics at the Florida State University College of Medicine. “But everyone who is older is at increased risk.”
One reason Pregler cites could be the repercussions of a unique moment in America’s history. “The Summer of Love was 1968, and I think the people who were 18 years old then are 68 now. We have a generation now in those older years who came of age at a medically unusual time,” meaning that “prior to the onset of the antibiotic era, sexually transmitted illnesses were a very serious thing. People died of syphilis,” but the advent of antibiotics meant that common STIs like gonorrhea and syphilis could be cured. The arrival of the birth control pill also reduced the chances of unwanted pregnancy, freeing young people in the 1960s and 1970s to become more sexually carefree than their predecessors.
“Suddenly, we had this period of time where there really weren’t sexually transmitted illnesses that could kill you. Certainly, people got herpes and that could be distressing, but in terms of sexually transmitted illness being a life-or-death matter, there was that period of time where it really wasn’t looked at that way,” Pregler says. Now older, some members of that generation may have recently lost a long-time partner, and perhaps are becoming sexually active again with a new partner or partners in a changed landscape.
Granville echoes this thought. “This population did not initiate their dating years and involvement with others at the time that HIV and other serious infections were prevalent, and so they’re of the belief that the common infection is gonorrhea, and that penicillin can fix the problem. I think there was a little less concern and awareness about the possibility of life-threatening infections being acquired then.” This attitude may be compounded by the fact that “they often have been off-the-market, so to speak, and not dating for many years as they’ve been involved with monogamous relationships. But as they age and those relationships end, commonly through death though we know divorce is becoming more prevalent, they find themselves dating and they really don’t have the tools and knowledge and skills to be back in the dating market.”
Although in many cases, multiple STIs occur in the same patient together and increases are being seen across the board, Lindau says the rise in gonorrhea rates is particularly worrisome, “because the medications we’ve used in the past to treat gonorrhea are proving less and less effective” due to antibiotic resistance. Trichomoniasis is also spiking in middle-aged adults, and she says HIV is a third area of concern, because “as doctors, we tend to be less likely to talk to our patients about HIV and we’re less likely to screen or counsel about testing. Therefore, HIV is likely to go undiagnosed,” which can lead to its unwitting spread.
This lack of screening may stem from a common oversight during annual visits. Pregler says that when she sees a Medicare patient for an annual wellness exam, “the federal government requires us to do many, many things. We have to assess vision, hearing, memory and whether the patient is falling down. But there’s no requirement to ask them about their sex life.” It’s hard to find what you’re not looking for, so Pregler says this blind spot toward sexual activity and its potential consequences among older adults could be contributing to the rise in rates. “If we’re not testing and not treating, that means there’s going to be more sexually transmitted infections in the population.”
Plus, “doctors are often very busy, and this isn’t usually the first thing that comes to mind to address,” Granville says, “especially with older populations that have multiple comorbidities. When I’m caring for someone with diabetes or high blood pressure, I don’t always get to all the preventive issues that I should, and so these things often get pushed off to the next visit and the next visit,” Granville says.
What’s more, “decreasing or insufficient funding of public health infrastructure, which is the main pathway through which the American public gets preventive information including about sexually transmitted infections” could also be contributing to a rise in rates, Lindau says.
On the flip side, Granville notes that there is the possibility that the actual incidence of sexually transmitted diseases hasn’t increased, but an improvement in detection is leading to higher reported numbers. She says “the baby boomer generation that’s coming up is now much more informed and proactive” about matters surrounding what may have formerly been treated as hush-hush topics by older generations. This may lead some older adults to be more willing to visit a doctor if they’re experiencing symptoms of a potential STI.
Another potential reason for the increase could be newer drugs, Lindau says. “Thanks to effective medications approved by the FDA to treat sexual dysfunction in men and women, we may see more sexual activity in older age groups than we did 20 or 30 years ago. More sexual activity does increase the probability of sexually transmitted infections in the population, especially if the population is not targeted with effective messaging either from the public health sphere or their doctors about safe sex.”
While several factors are likely contributing to the uptick in STIs in seniors as noted, the key to curbing these diseases is good, old-fashioned knowledge. Education and communication — both between sexual partners and between patients and health care providers — are critical to curbing the transmission of sexually transmitted infections no matter how old you are.
Granville says that while it’s important for patients to talk to their doctors about sexual activity, it’s also incumbent upon health care providers to eliminate any preconceived notions about what their patients are doing. “We should never assume that because people are old, they aren’t having sex. In fact, I would assume the opposite. Sex is a very natural, human interaction that people enjoy. Even those who are the frailest and bedbound are still having sex.”
She relates the story of a bedridden patient who came into the hospital where Granville was training staff. “I asked the staff, ‘Did you ask him about sexual activity?’ And they said, ‘no. He’s bedridden. How would he do that?’ I looked at them and said, ‘Where do you have sex? Most people have it in a bed, so why would you think being bedridden eliminates it? It’s just like Domino’s (pizza). It can come to you, you don’t have to go to it.’ They had clearly decided frailty plus bedbound equaled no sex. Nope. Bedbound means already in position and easy to have sex. Change your thoughts.” She says this sort of practical approach to sex in older adults can help them stay safer and enjoy sex more.
Making sure patients have the information they need about safer sex options is also important, Lindau says. Although some older adults may have only thought of using a condom as a younger person to prevent unwanted pregnancy, they’re also effective in preventing the transmission of STIs. “There’s a public health campaign that was developed for the UK called ‘Age is not a condom,’ and I think that’s very smart. Age does not protect you against sexually transmitted infections.” But an actual condom might. “Condoms are very important for everybody who’s having sex with a new partner and with a partner who hasn’t tested negative for sexually transmitted infections and HIV.”
She notes that there are both male and female condoms, and for older adults, the female version might be a better option. “We don’t hear much about female condoms, but one of the challenges for older men using a condom is that it needs to be applied when the man has a full erection. For some older men, they don’t really get a fully firm erection until after vaginal penetration. If this is a problem a couple is experiencing, a female condom could be an alternative.” ( Planned parenthood offers more information about these devices.)
And making condoms for both men and women more universally available may also help curb infection, Granville says. “In the university system where I practice, we have condom dispensers everywhere. They’re outside the lockers, they’re in the middle of student health centers. We don’t do that as much in older adult residences,” such as assisted living communities, nursing homes and other long-term care facilities. “But maybe we should. Maybe we should just make these things overtly present and accessible. Then people don’t have to be embarrassed or unsure of what to use and how to use it.” These residences, after all, bring people together and could lead to people finding new sexual partners.
Anyone who is sexually active is potentially at risk of contracting a sexually transmitted disease, but among women, the risk of contracting an STI can increase with age as the hormonal balance in the body changes. After menopause, estrogen levels fall, which can lead to thinning of the tissues of the vagina and vulva and vaginal dryness. During intercourse, this thinner, drier tissue is more likely to tear, leading to micro abrasions that offer more points of entry for infectious agents like HIV. Additionally, women who are taking aromatase inhibitors — an estrogen blocking medication that’s often used to treat breast cancer in post-menopausal women — can further thin the tissue and set the stage for easier transmission of pathogens.
Granville adds that other medicines can also alter aspects of your sexual health, so check with your doctor about whether that’s a potential side effect of any of the medications you’re taking. “There’s also a lot of new information as we look at the microbiome,” she says, which refers to the host of good bacteria that inhabits various parts of the body to help keep things in check. Similar to how we know that there’s good bacteria that live in the intestines that keep us healthy, “we know that there’s normally good bacteria in the vaginal area helping to prevent infections there as well. These things get disrupted by a variety of means including medication.” Again, a frank conversation with your doctor can help you determine whether you’re at risk and how best to avoid getting sick.
Lindau emphasizes that “while I do think it’s important to call attention to safe sex in later life, I think it’s important to point out that we don’t see evidence of a major epidemic of sexually transmitted infections among older adults.” And because the rates of infection are relatively low in this population, that can impact how screening tests work. “We do see more false positives in populations with a low rate of the disease, so people who have a (positive) screening test should have it verified before panic sets in.”
Lastly, “if you have developed new symptoms concerning for sexually transmitted infections like discharge, pain, fever or sores in the genital area, see a doctor,” Lindau says. And if you have tested positive for an STI, know it’s not hopeless. “There are effective treatments for most sexually transmitted infections.” While prevention is always best, “it’s certainly better to seek medical care than to ignore the symptoms. And especially with HIV, it’s not a death sentence. It’s an infection that can be treated in much the same way as other chronic diseases. But it must be treated.”
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