Can you imagine being told in later life that you shouldn’t be having sexual thoughts or that watching a risqué TV show is “too sexy for someone your age”? Or even that you are “too old” for sex and shouldn’t be considering it?
Believe it or not, that’s the reality for many older adults, not just in Australia, but in other Western countries around the world. And, what’s more, as our research has shown, they are hearing these views from healthcare professionals.
It’s a bit perplexing why society generally and healthcare professionals in particular, continue to believe ageist stereotypes which position older adults as asexual.
Remaining sexually active in later life is good for our overall health and wellbeing, as well as our cognitive ageing; and increasing evidence shows that people can and do remain sexually active well into their 80s and beyond.
Despite this, many health professionals don’t ask their older patients about sexual health and wellbeing matters, waiting instead for their patients to bring them up.
The trouble is, many older adults have been raised in eras when sex was not talked about, so they don’t ask either.
This Catch-22 means the sexual health of older adults is often going unaddressed.
Divorce rates in later life are going up (and so are STI rates)
The problem is that previous research in 2012 by dating site RSVP.com found older daters are most likely to have sex on the first date. Older men are less likely to use condoms than younger men and older women are less likely to refuse sex without a condom than younger women.
The reasons why are unclear but it appears to be related to low levels of sexual health knowledge coupled with inadequate sex education historically, meaning that few older adults are aware of safer sex practices and the protection condoms can provide.
As a consequence, sexually transmissible infections (STIs) in older populations are rising. For instance, the number of diagnoses of chlamydia, gonorrhoea and infectious syphilis in Australians aged 60 increased by almost 50 per cent between 2012-2017.
While the numbers are relatively low compared to other population groups, they are likely to be under-reported because of issues of stigma, and because STIs can show no symptoms, or the symptoms can go unrecognised by both older patients and their health professionals.
Another important consideration is that sexual difficulties like maintaining an erection, lack of sexual desire or problems with lubrication increase in later life. Older patients may therefore not be receiving the care they need simply because these issues are not being discussed by them or their GP.
We undertook the Sexual Health and Ageing, Perspectives and Education (SHAPE) series of projects to investigate attitudes to sexual health discussions in general practice and to identify how we can encourage these conversations to happen more often, and more effectively.
The SHAPE Projects
We started by asking 21 older Victorians about their experiences of discussing sexual health matters with their GPs. We also asked 27 Victorian-based health professionals (GPs, practice nurses and practice managers) about their knowledge, attitudes and practices regarding the sexual health of older patients.
We found most health professionals had limited formal education about ageing and sexual health, apart from a focus on dysfunction. Later life sexual wellbeing was something most of them didn’t consider relevant to their older patients.
As one GP observed:
“…I suppose you grow up thinking people of that age don’t have sex.”
Health professionals also told us they wanted any discussion about sexual matters to be ‘patient-led’, although our older patients said they wanted their doctors to do the asking.
They also thought it was vitally important that sexual health and wellbeing was embedded as part of their routine care, and no more unusual than things like blood pressure monitoring or flu injections.
As one older woman aged in her 60’s told us:
“In the GP world, there seems to be a view that… nothing happens between my neck and my knees... we’re still sexual beings… it’s just a normal part of who we are.”
For those older people who had talked to their doctors, their experiences had been less than satisfactory, with some GPs dismissive or condescending in their attitudes.
An older man told us:
“My GP has never initiated a sexual health discussion with me. His response [to my enquiry] was ‘Memories, we have memories’ and ‘you just have to cope’.”
Short consultation times and the number and complexity of medical issues experienced by many older patients also impacted on a GP’s ability – and willingness – to address sexual health and wellbeing issues.
We also asked older patients and key informants what kind of support could help these conversations happen. The majority were in favour of using some kind of resource to guide the discussion, suggesting it could help build confidence on both sides.
An electronic checklist was seen as suitable for older patients because of its ease of use and anonymity.
Older patients welcomed the opportunity to use this kind of resource within clinic waiting rooms, provided the information was given directly to doctors and not via reception staff.
Next, we set out to investigate the content, format, language and tone of a sexual health discussion checklist in consultation with older patients.
We found they preferred informal language with questions covering four key areas: common clinical questions (about matters like incontinence, erections and lubrication); issues they’ve wondered about but never discussed with their GP (like masturbation or orgasms); questions about changing partnership status (like safer sex issues); and general ‘other areas’ of concern.
We tested a draft version of the checklist (in both digital and print formats) with focus groups of older Australians, receiving positive feedback on how easy it was to use and understand.
The purpose of the checklist was also very clear - a male participant told us:
“While it’s supposed to help me, I have no doubt it’s also helping the doctor and the staff to discover other health issues they might not have been aware about.”
The next phase is to test the acceptability of the checklist in general practice clinics and we are currently seeking funding for this.
As sexual health and wellbeing becomes an increasing focus of care in later life, it’s vital that GPs are open-minded, respectful and knowledgeable on the topic. We’d like to see more education for GPs in this important area.
Digital interventions or aids have gained popularity in GP clinics in recent years and are already being used to facilitate discussions, particularly about difficult or sensitive topics.
Our SHAPE checklist has the potential to become another tool available to GPs, to help start breaking down some of the old-fashioned and debilitating taboos about sex in later life.
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