Sex, older people, elderly people, and sexually transmitted infections

Instances of sexually transmitted infections in over-45s are increasing. Anne Gulland asks what is causing the trend and what can be done to ensure people receive the treatment they need

Social workers who work with children and young people are used to talking about sexual health with their clients, but many might think twice about talking about sex with people old enough to be their grandparents.

But they might be forced to raise this taboo subject as increasing numbers of older people are contracting sexually transmitted infections (STIs).

A study by the Health Protection Agency in the West Midlands, published in the June edition of the journal Sexually Transmitted Infections, found that there was an increasing rate of sexual infections in people over the age of 45. The study looked at the numbers of people attending genito-urinary medicine clinics for STIs between 1996 and 2003.

In 1996 the over-45s comprised 3.9% of all clinic visits, but by 2003 this had risen to 4.5%. Of the over-45s, men and those aged between 55 and 59 were more likely to be affected, with the most commonly diagnosed infection among over-45s being genital warts, accounting for 45% of cases. Herpes was the next most common, affecting almost one in five (19%).

Helpline survey

A survey by the Family Planning Association last year found that almost 10% of callers to its helpline were over the age of 45, with the oldest caller being 68.

As people are living longer and healthier lives, an active sex life becomes more important, says Judith Milner, former social work lecturer and co-author of Sexual Issues in Social Work. “Sexual activity is an important part of self perceptions of well-being, which contributes to longevity and health,” she says.

“Many elderly people talk about sexual activity as being even more important as they get older.”

She and co-author Steve Myers, director of social work at Salford University, firmly believe that social workers should address older clients’ sexual health and sexuality head on.

Myers says: “Social workers need to talk to everyone about these issues – it’s about acknowledging that it’s an important part of people’s self-image and well-being. People don’t like to think about older people being sexual beings but it’s self-fulfilling – if we don’t talk about it then it will remain hidden. A lot of older people would like to reclaim these bits of their youth, they want to reclaim their sexual identity.”

Acknowledging that someone old enough to be your grandparent is having sex can be difficult, but a quick trawl through the Dear Gwen agony aunt column on the Age Concern website will show that plenty of older people have an active sex life. Raising this subject with clients does not have to be awkward, say Myers and Milner.

Oblique questioning

Social workers should use their communication skills and oblique questioning techniques to tease out any concerns older clients might have, says Myers. They could ask questions such as: “What needs to happen differently for you to live a full life?” “How do you feel about your body?” “What question have I not asked that you wished I had asked?” “What’s important to you that I have missed?”

The increase in the number of STIs among older people can be put down to a number of things, says Babatunde Olowokure, the consultant epidemiologist who carried out the Health Protection Agency study.

“Older people are increasingly likely to be single or undergoing relationship changes and are less likely to consistently use condoms, perhaps because the risk of pregnancy no longer exists,” he says.

“Increased international travel, internet dating, new drugs to counter erectile dysfunction and overlapping sexual networks [people sharing the same partners] may also be factors.”

According to figures from the Office for National Statistics about 38,000 people over the age of 50 went through a divorce in 1995, compared to 55,000 in 2005. It is in the older population that the divorce rate is increasing the most.

Sue Scott, professor of sociology at Keele University, says older people coming out of long-term relationships are like teenagers in their attitude to sex – they are embarrassed to talk about it.

“We think of the life course as linear and we learn more about most things as we go on. But people in their 20s will have grown up with things such as HIV and chlamydia and they will be much more knowledgeable about these matters than people in their 40s or 50s,” she says.

“A woman embarking on a new relationship in late life will not have the skill to say ‘how many relationships have you had?’ This is very difficult unless you’re very confident.”

Safer sex campaigns have traditionally targeted young people, but Olowokure calls for health services to ensure that older age groups are not missing out on any key health messages.

Myers says social workers are well placed to deliver that message: “Free condoms and sexual health leaflets would be a really helpful part of any service for older people. Websites would also be helpful – there are an awful lot of silver surfers out there. It’s empowering for people to access information themselves.”

But Mark Pakianathan, consultant physician at the Courtyard sexual health clinic at St George’s Hospital in south London, warns against the notion that there is a tide of older people demanding treatment for gonorrhoea – 80% of his clients are under 35 – but acknowledges that more older people are now seeking his services.

Vulnerable groups

He even treated a 98-year-old last year. Patient confidentiality prevents him from divulging his history but he adds: “Some elderly men have quite a good life.”

Certain groups are more vulnerable to STIs: men who have sex with men, and men who pay for sex. But he adds: “It’s certainly true that a woman in her 50s who is coming out of a long-term relationship is vulnerable to STIs.”

He also says that an older person with an STI is more likely to be affected psychologically: “A 48-year-old who finds themself in a sexual health clinic will suffer from the stigma. They’re a bit out of the loop they’ll find the clinic environment more difficult.”

He acknowledges that this clinic environment is geared towards younger people, with copies of Heat magazine strewn about and youth-oriented TV channels on in the waiting room.

“I hope we are sensitive to these people. But the ones I’m concerned about are the ones I don’t see who need to access our services,” he says.

Pakianathan says that a targeted, safer sex campaign for older people is necessary as many older people would have missed out on such messages when they were young.

“If you look at a divorced woman in her 50s or 60s, the last time she was out and about was probably pre-HIV. It was a time of the post-60s, flower power revolution. I suspect that buying condoms was not a reality for her.

“This is a group that’s vulnerable – the numbers [of STIs] are still small but when it becomes endemic, like it has done in the under-25s, then it’s too late,” he says.

• Recommended reading: Steve Myers and Judith Milner, Sexual Issues in Social Work, Policy Press, 2007

Published in the 24 July issue of Community Care under the headline Sex in the Middle Ages