STI % Rising Among Sexually Active Older Adults

No matter what age you are, if you are sexually active, you are not immune to sexually transmitted infections.

I found the information shared in the last comment to article, most disturbing.

Sexual health and the older adult

Trends show that doctors must be more vigilant

  • By: Rachel von Simson, Ranjababu Kulasegaram
  • Published: 02 February 2012
  • DOI: 10.1136/sbmj.e688
  • Cite this as: Student BMJ 2012;20:e688

A 56 year old man has trouble with his “waterworks.” A 61 year old woman reports lower abdominal pain. The chances are that sexually transmitted infections are not high on your list of differential diagnoses—but increasing evidence indicates that they should be. A cross sectional study showed that more than 80% of 50-90 year olds are sexually active[1] with cases of many common sexually transmitted infections more than doubling in this age group in the past 10 years.[2]

The recently published Health Protection Agency report on HIV in the United Kingdom shows that 20% of adults accessing HIV care are older than 50, up from 11% in 2001.[3] This is in part because of prolonged survival; however, new diagnoses in over 50s doubled between 2000-9 to account for 13% of the total.[4] Although this is low in proportion to the population percentage aged over 50, this is not a group traditionally considered at risk. The result of this low index of suspicion is worrying—62% of new diagnoses in over 50s were “late” (defined as a CD4 count of <350), and late diagnoses in older adults are associated with poor outcomes; older adults presenting late are twice as likely to die than younger adults diagnosed late.[5]

The rise is not confined to HIV or the UK. In England, between 2000 and 2009, diagnoses of sexually transmitted infections in over 45s doubled, to almost 13 000 cases.[6] Centers for Disease Control and Prevention statistics for the United States showed that, although there were 706 diagnoses of infectious syphilis among adults aged 45-54 and 179 in those aged 55-64 in 2000, by 2010 this had risen to 2056 and 493 respectively.[7] For chlamydia, there were 5601 diagnoses in adults aged 45-54, and 1110 in adults aged 55-64 in 2000, but by 2010 this had risen to 16 106 and 3523 respectively. Similarly, in Canada between 1997 and 2007, cases of gonorrhoea among adults aged 40-59 increased from 379 to 1502, chlamydia cases increased from 997 to 3387, and infectious syphilis from 34 to 527 cases. This compared with an increase in syphilis in adults aged 15-29 from 36 to 248.[8]

The reason behind the increase in sexually transmitted infections is unknown and little research has been done. Older women are more vulnerable physiologically. Post-menopausal changes to the vagina, such as thinning of the mucosa, narrowing and shortening of the vagina, and decreased lubrication leave women more vulnerable to minor genital injuries and microabrasions that facilitate the entry of pathogens.[9] After the menopause, vaginal pH increases from 3.5-4.5 to 5.0-7.5,[10] and a higher vaginal pH has been associated with an increased risk of contracting chlamydia and gonorrhoea.[11]

Although physiological changes might explain why older women are more likely to contract an infection if exposed, they do not explain why older adults are increasingly exposing themselves to risk. One theory has been that the development of phosphodiesterase type 5 inhibitors to treat erectile dysfunction has allowed men to stay sexually active, and therefore at risk, beyond previous limits. However, a US study of men over 40 who were claiming sildenafil on their insurance found that, although men were significantly more likely to be diagnosed with a sexually transmitted infection within the first year of usage compared with controls, they were also significantly more likely to have been diagnosed with a sexually transmitted disease in the year before starting it. This suggests that the drug does not alter risk taking behaviour but does facilitate it.[12]

Without a great deal of evidence about the reason for the increase in sexually transmitted infections, it is difficult to know what strategies will work to raise awareness and control the spread of infection. In 2010, the sexual health charity FPA launched a campaign week entitled “The Middle Aged Spread” to raise awareness among older adults and health professionals.[13] The campaign generated substantial press interest, but there was no analysis of its efficacy and no follow-up campaign.

The authors of the sildenafil study suggested that doctors should take the opportunity to discuss safe sex with those seeking drugs for erectile dysfunction because they have a high risk of contracting infections.[12] Evidence shows that targeting high risk older adults can be effective. A randomised control trial in the US assessed the efficacy of telephone administered motivational interviewing to reduce risky sexual behaviour in HIV positive adults who are over 45. Telephone administration was chosen because older adults with comorbidities may be less able to travel to traditional services. Participants were allocated to no intervention, one motivational interviewing session, or four. Follow-up at three and six months showed that those who had undergone four sessions had engaged in significantly fewer acts of unprotected sex compared with controls and those undergoing one session.[14] The difficulty is in identifying which older adults would benefit from such targeted interventions.

Research on knowledge about sexually transmitted infections, sexual behaviours, attitudes toward condom use, or prevalence of undiagnosed sexually transmitted infections in older adults in the UK is currently lacking. The third National Survey of Sexual Attitudes and Lifestyle (NATSAL), due for publication in 2013, will possibly provide some answers because, for the first time, it includes adults up to the age of 74. Until then, doctors should maintain a low threshold for investigating sexual transmitted infections in older adults and should not shy away from discussing safe sex with patients, regardless of their age.

Rachel von Simson, final year medical student1, Ranjababu Kulasegaram, consultant genitourinary physician2

1King’s College London, 2St Thomas’s Hospital, London

Correspondence to: rachel.von_simson@kcl.ac.uk

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

  1. Gott CM. Sexual activity and risk-taking in later life. Health Soc Care Comm 2001;9:72-8.
  2. Health Protection Agency. Table 4: number of selected STI diagnoses made at genito-urinary medicine clinics by gender, sexual orientation and age-group, UK, England and English SHAs: 2000-09, 2010.
  3. Health Protection Agency. HIV in the United Kingdom: 2011 Report. Health Protection Agency, 2011.
  4. Health Protection Agency. HIV in the United Kingdom: 2010 Report. Health Protection Agency, 2010.
  5. Smith RD, Delpech VC, Brown AE, Rice BD. HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS 2010;24:2109-15.
  6. FPA.FPA warns of rising STIs and poor sexual health in the over 50s. 2010 www.fpa.org.uk/pressarea/pressreleases/2010/september/fpa-warns-of-rising-stis-and-poor-sexual-health-in-the-over-50s.
  7. Centers for Disease Control and Protection. Sexually Transmitted Disease Survelliance Annual Report 2004 and 2010. 2011.Error! Hyperlink reference not valid..
  8. Bodley-Tickell AT, Olowokufre B, Bhaduri S. Trends in sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Sex Trans Inf 2008;84:312-7.
  9. Poulos CS. Genital injuries in postmenopausal women after sexual assault. J Elder Abuse Neglect 2008;20:323-35.
  10. Stika CS. Atrophic vaginitis. Dermatologic Ther 2010;23:514-22.
  11. Das S, Allan S. Higher vaginal pH Is associated with Neisseria gonorrhoeae and Chlamydia trachomatis infection in a predominantly white population. Sex Trans Dis 2006;33:527-8.
  12. Jena AB, Goldman DP, Kamdar A, Lakdawalla DN, Lu Y. Sexually transmitted diseases among users of erectile dysfunction drugs: analysis of claims data. Ann Int Med 2010;153:1-7.
  13. FPA. Sexual Health Week 2010: the middle aged spread (STIs in the over 50s), 2010.
  14. Lovejoy T, Heckman T, Suhr J, Anderson T, Heckman B, France C. Telephone-administered motivational interviewing reduces risky sexual behavior in HIV-positive late middle-aged and older adults: a pilot randomized controlled trial. AIDS Behav 2011;15:1623-34.

Cite this as: Student BMJ 2012;20:e688

Responses to this article

11:49 4 February 2012

johnb123 says:

I’d like to see the break down between  homosexuals and heterosexuals. That would make a big difference.

08:22 3 February 2012

marathoner42 says:

Enjoyed your article immensely, but let me caution you as to your (most likely, unknowingly and innocently) not mentioning the group which never gets reported: the greater than 65 year old crowd. I was never privy to this out-of-contro group until I retired to Florida. But, there is a reason to believe that statistically this crowd accounts for the highest HIV rate (at least in Florida where men my age and older acquired the sobriquet “Condo Cowboys”). I, myself, am 69 and single so I have met a lot of men, marriage not even being a considered thought, joyously bloviate about their sexual escapades and conquests. Ane, the one admission that seems to preponder is that “at my age” the thought is “who cares about consequences” when I am going to die soon anyway. And, this is a cold, hard fact. I caution you (with gerontological considerations in mind as well as longevity with greater and more insightful medical care now a very pertinent consideration) to (not necessarily focus on) consider this “rising” (no oun intended) group of philanderers. And, there is an ever expanding group like myself: 69, longtiming marathoner (77 in number), never taken any kind of medication for anything, disease free, appearing physically like a 45 year old, excellent diet never having eaten red meat, excess salt or sugar, never needing the need of Viagra,etc. and very sexually careful. Now, I am not expounding because I am a freak of nature, I am trying to point out that this ever increasing group (into which I find myself) is replete with septuagenarians and octogenarians who possess a carefree, careless, diseases-be-damned attitude!! Sorry for the harangue, but this is the group your well crafted article does not cover–and, it is very much an out-of-control, bold and brazen group of sexually directed bonvivants!! Thank you, Robert Allyn Goldman, Palm Beach Gardens, Florida.

http://student.bmj.com/student/view-article.html?id=sbmj.e688

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