Let's Talk About Sex—After 60

Source: Flickr/"Older couple"

Let’s talk about sex—after 60 is part one of a three-part series exploring sex and aging. Part I, below, provides an overview of the issues surrounding sex in later life. Parts II and III will feature interviews with thought leaders on the subjects of sexuality and age, including Esther Perel, a therapist and the author of Mating in Captivity: Unlocking Erotic Intelligence and most recently, The State of Affairs: Rethinking Infidelity as well as with Dr. Martha Nussbaum, a philosopher, professor of law and ethics at the University Chicago, and a co-author of Aging Thoughtfully: Conversations about Retirement, Romance, Wrinkles, and Regret, written alongside Dr. Saul Levmore. Check Eng(aging) for parts II and III, which will be published over the next few weeks.

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Overview

Source: Flickr/"Older couple"

Later life sexuality has received increased empirical attention as gains in longevity continue (Syme & Cohn, 2016). We're learning that older folks get busier than we think, with a seminal study finding that 73 percent of people aged 57 to 64 and 53 percent of people between 65 to 74 years reported engaging in sexual activity during the previous year (Lindau et al., 2007). As with other periods of development, sex after 60 enhances the quality of life and promotes physical and psychological well-being-- improving cardiovascular function and reducing depression (Zannie et al., 2005; Bauer et al., 2007; Syme & Cohn, 2016).

Epidemiological trends of STIs in later life

Source: Flickr/ "Old couple"

Notwithstanding, rises in rates of sexually transmitted infections (STIs) among older adults (OAs), including HIV (Ports et al., 2014; Emlet et al., 2011), point to discrepancies in sexual health communication and knowledge on systemic and individual levels. Compared to their younger counterparts, for example, older adults appear less knowledgeable about STIs (Syme & Cohn, 2016), underestimate their risk for infection (Syme et al., 2017), and practice safe sex less often (Reece et al., 2010), heightening their vulnerability to disease (Ports et al., 2014). Epidemiological data from the Centers for Disease Control and Prevention (CDC) reflect this, reporting that adults over 50 represent 15 percent of new HIV infections (CDC, 2013), further forecasting that by 2020, upwards of 70 percent of persons living with HIV will be 50 and older (Tietz, 2013). Prevalence rates of other infections – including chlamydia, gonorrhea, primary and secondary syphilis—show similar increases among older adults (AARP, 2010).

What’s going on?
For HIV specifically, these data reflect the confluence of (1) long-term survival with HIV and (2) the rising incidence of infection among adults 50-plus (Emlet et al., 2011); the latter explanation extending also to observed increases in other later-life STIs, like chlamydia. We can, as a culture and individuals, probably digest the first reason with little resistance: antiretroviral treatment advances have simply permitted infected adults to achieve life expectancies commensurate with those of their uninfected counterparts (Nightengale et al., 2014), inflating prevalence. But the second reason—growth in new infections altogether—means recognizing that sex that does not retire after 60.

A biopsychosocial explanation
So what, exactly, underlies the incidence of STIs, like HIV, in older folks? A complex cocktail of biopsychosocial factors (physiological, behavioral, and cultural contributions) that interact to produce health outcomes (Engel, 1977).

Source: Flickr/"65 Years Together"

Biological factors
From a purely biological perspective, older adults experience normative changes in immune function that can increase their vulnerability to sexually transmitted infections (Zelentz et al., 1998). For example, decreases in T cell number and maturity, weakened cytokine production, and cell responsivity, combined with other metabolic factors, can depress lymphocyte sensitivity and aid the pathogenicity of infections (Zelentz et al., 1998). Further, thinning of the vagina and anal mucosa due to systemic reductions in testosterone and estrogen as well as decreases in vaginal lubrication, leave older women and men more susceptible to tears during sexual activity that facilitates viral entry. Unfortunately, most older adults lack knowledge about sexually transmitted diseases and the physiological changes accompanying aging that leave them vulnerable to STIs, in turn, maintaining disease and dysfunction (Syme & Cohn, 2017).

Psychological factors
These biological vulnerabilities intersect with the psychological biases older adults themselves harbor about sexuality and aging, particularly baby boomers who appear to underestimate their vulnerability to contracting STIs (Syme & Cohn, 2017). A study comparing actual versus perceived sexual risk among older adults found that the accuracy of risk evaluation decreased in tandem with increases in actual risk, reporting that 93.1 percent of the highest risk adults in the sample underestimated their vulnerability (Syme & Cohn, 2017). The consistent finding that older adults practice safe sex less often than younger adults reflects these blind spots and biases (Ports et al., 2014; Ngugen & Holodniy, 2008) and may stem from cohort differences surrounding the rise of penicillin during in the 1960s and 1970s successfully treating STIs like syphilis that skew OAs’ identification with risky sexual behavior. Further, the intersection of menopause with the proliferation of pro-erection medication (i.e. sildenafil; Lindau et al., 2007) in a climate of shifting divorce and dating patterns in later life (Cooney & Dunne, 2001) have coalesced to create more opportunities for sex in later life, adding significant complexity to the management and treatment of sexual issues.

Sociocultural factors
Older adults, of course, aren’t entirely to blame. Societal myths and mores about aging and sexuality (e.g. sex is for the young, healthy, and beautiful; older adults are asexual or monogamous at best) perpetuate stigma surrounding late-life sex, trickling down into clinical settings and healthcare services (Angus & Reeve, 2006) that reinforce older adults’ internalized distortions about sex (Syme et al., 2017).

Impact

Source: Flickr/Fuvahmulah

STI prevention and control guidelines require comprehensive sexual history taking (CDC, n.d.), emphasizing the need for all adult patients to receive information about STI risk and ways to reduce that risk (Ports et al., 2014). Despite these recommendations, rates of physician-initiated sexual history taking remain suboptimal, particularly among older adults (Slinkard & Kazer, 2011). A recent study revealed that few men (38 percent) and even fewer women (22 percent) had discussed sex with a physician since age 50, notwithstanding recognition of sexual health as an integral part of overall health and successful aging (Lindau et al., 2007). Unsurprisingly, increasing age appears to have an inverse relationship with documented sexual history (Loeb et al., 2011), suggesting that practitioners’ attitudes and beliefs about sex in later life may stem from stereotypes of aging and sexuality, rather than experiences with, or explicit education about, older patients (Gott et al., 2004). Reflecting this, healthcare providers underestimate the prevalence of their patients’ sexual concerns, often equating sexual health needs with younger people and expressing discomfort with discussing sexual health with older patients (Ports et al., 2014). Many advocates implicate lack of formal training in the understanding, treatment, and assessment of late-life sexual issues (Ports et al., 2014): take that even when nurses in aged care settings are prepared to initiate discussion, many are untrained to (Parker, 2006). All of this, despite evidence that most health care professionals agree that addressing sexual health issues ought to be part of the holistic care of patients and that older adults would welcome and desire such discussions (Aizenberg et al., 2002).

Now what, and what next?

Source: Flickr/ "Just watching the world together"

Where do we go from here? Hearteningly, emerging (but scant) evidence supports my hunch that education may be a good start. Across settings, including in community health centers and nursing homes alike, providing education has been shown to increase permissive attitudes toward aging and sexuality among providers (Syme et al., 2017; Hammond, 1979; White & Catania, 1982). Most recently, internal medicine residents who received an educational intervention consisting of three, 30-minute sessions on sexual history taking demonstrated improved documentation of sexual histories among older folks versus those who did not (Loeb et al., 2010).

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Borrowing from these and other models, psychologists specializing in (or simply working with) older adults have a moral imperative, given their training, to develop, implement, and evaluate the effectiveness of standardized adult sexual education protocols for practitioners, middle-aged, and older adult patients on, among other things;

• Increasing knowledge and education about sexual health and functioning, as well as their changes, in later life;
• Promoting understanding of the biopsychosocial contributions to sexual risk behaviors in later life, their prevention, and management; and
• Facilitating growth in physician and patient perceived self-efficacy to assess, discuss, and treat sexual (dys)function.

This approach (incidentally the subject of my dissertation) may provide a sustainable, economical solution to staggering increases in sexual disease and dysfunction in later life.

After all, sex—and the education that ought to accompany it—isn’t just for the young and beautiful.