SEXUALITY AND SEXUAL HEALTH
OF THE OLDER ADULT
Carrie Plummer, RN, MSN, ANP – BC
Vanderbilt School of Nursing
September 30th, 2010
OBJECTIVES





Describe the aging of North America and the affect of the “Baby
Boomer” generation on the health care system.
Describe ageist assumptions regarding older adult sexuality and
their affect on health care provider attitudes.
Identify normal and abnormal processes of aging and how these
processes impact on the older adult’s sexual health.
Describe risky sexual behaviors in older adults and the
correlation with increased rates of sexually transmitted
infections (STIs) in people >60 years old.
Identify methods by which health care providers can incorporate
sexual health history questions and education into routine patient
care.
OUR AGING SOCIETY - THE REALITY


“During the 20th century,
the average lifespan in the
United States increased by
more than 30 years; 25
years of which can be
attributed to advances in
public health.”
Taking part in “active
living” includes emotional
and physical expressions of
connection with others.
http://en.wikipedia.org/wiki/Life_expectancy
http://www.flexphysicaltherapy.com/images/img-innovative.jpg
DEMOGRAPHIC DATA ON OLDER ADULTS
IN THE U.S.




Currently, approximately 12% of U.S. population
>65 years old
The “Silver Tsunami”: by 2030 – 20% or 71.5
million of U.S. population >65 years old
AARP “Sexuality and Maturity” 1999 – 43% of
men and 35% of women aged >55 reported having
sex at least once a week.
In 2003, the number of U.S. women on HRT
declined from 42% to 28% after Women’s Health
Initiative published their report in 2002.
DEMOGRAPHIC DATA ON THE FRAIL
ELDERLY


An estimated 5% of people
age 65 and 20% of those
over 85 will spend time in
a long term care facility.
A study of 15 Skilled
Nursing Facilities in
Texas, with the mean age
of 82 years, 81% of men
and 75% of women
reported sexual desire, but
were currently sexually
inactive because of lack of
opportunity.

Hajjar, R. R. & Kamel, H. K.
(2003)
SEX IN THE ASSISTED AND LONG TERM
CARE FACILITY

What other factors come into play in these setting(s)?






Dementia
Frailty
Staff attitudes
Family attitudes
Liability
Newsweek article

http://www.newsweek.com/id/60906?tid=relatedcl
AMERICAN PSYCHOLOGY ASSOCIATION
AGEIST MYTHS:






Increasing age brings about
greater psychological distress.
Older adults are more depressed
than younger adults.
As individuals reach old age,
they become preoccupied with
memories of their childhood
and youth.
Older adults are less satisfied
with their lives than younger
adults.
Older adults are alienated from
the members of their families.
Because older adults generally
do not reside with their
children; they rarely see them.







Increasing age brings about
a decline in sexual desire
and interest.
Older adults are not
physically capable of
engaging in sexual
intercourse.
Older adults are very isolated
from their communities.
Social contacts decrease with
increasing age.
Older women focus mainly
on keeping families
together.
Older women suffer from
poor physical health.
http://www.psichi.org/pubs/articles/article_38.asp
SEX AND SEXUALITY:
NATURE VS. CULTURE

What is sex?


What is sexuality?



How do we define sex or sexual activity in the U.S. in
2010?
How do men, women express their sexuality?
Does age affect expressions of sexuality?
What is sexy?

How do we, as a culture, create standards through
which our perceptions are shaped as to who or what is
attractive or desirable?
THE MEDIA AND REPRESENTATIONS OF
OLDER ADULT SEXUALITY
Britney Spears Video
The Daily Show:
http://www.thedailyshow.com/video/index.jhtml?videoId=2238
98&title=dirty-bird-special
The New York Times:
http://well.blogs.nytimes.com/2008/07/22/more-sex-for-todaysseniors/
SEXUALITY AND IMAGES OF HEALTH:
IS THERE A CONNECTION?
http://strategerie.files.wordpress.com/2009/02/hugh-jackman.jpg
http://www.wallpapergate.com/data/media/858/ScarlettJohansson_001.jpg
SEXUALITY AND IMAGES OF HEALTH:
IS THERE A CONNECTION?
http://todaysseniorsnetwork.com/Elderly%20man,%20walker,%20caregivng.jpg
http://www.hullcc.gov.uk/pls/xximages/docs/older_woman_in_hat.jpg
THE MEDIA AND WOMEN’S
SEXUALITY
Review of teenager/women’s magazines looking at
common themes regarding sex and sexuality.
 “Both kinds of magazines emphasized that it was
women's work and worry to control sexual expression”
 “Women in the 40-50-year-old age group were
portrayed as responsible for the emotion work and
sexual relations linked to their responsibility for
maintaining their marriages and fulfilling their tasks
of motherhood, especially through the monitoring of
the sexuality of their female children”
Clarke, J. (2009). “Women's work, worry and fear: the portrayal of sexuality and sexual health in US magazines for teenage and
middle-aged women, 2000-2007. Cult Health Sex. May;11(4):415-29.
SEX AND OUR AGING BODIES AND MINDS
What changes are normal?
What changes are abnormal?
What changes are indications
of physiological pathology?
http://askpearls.com/wpcontent/uploads/2010/07/3-Pearls-ofWisdom.jpg
What can we attribute to the
“typical” aging process?
PHYSIOLOGY AND PSYCHOLOGY OF AGING:
IMPACT ON SEXUAL HEALTH AND SEXUAL EXPRESSION

Women

Peri and Post-Menopausal changes:
Peri-menopause: early/mid forties onset for most women
including hot flashes, lack of sleep, irritability, depression
 Post-menopause: lack of estrogen causes thinning vaginal
walls, decreased elasticity, the vagina shortens and
narrows, and decreased lubrication during sexual arousal
 The Women’s Health Initiative – Hormone Replacement
Therapy (HRT)


Other Health Issues:


Chronic pain, hysterectomy, mastectomy, HTN, diabetes,
arthritis
Psychosocial stressors:

Family, Work, Stress, Depression, Sexual Trauma
PHYSIOLOGY AND PSYCHOLOGY OF AGING:
IMPACT ON SEXUAL HEALTH AND SEXUAL EXPRESSION

Men

Erectile Dysfunction (ED):
Up to 50% of men 50-69 years old and 70% of men ages 70
years and older are affected by ED.
HTN, diabetes, BPH and s/p prostatectomy, insufficient
testosterone, chronic pain, medications (beta blockers)
 Treatments – Viagra/Cialis, testosterone replacement,
penile implants, pumps, treat diabetes, pain management


Other Health Issues w/out ED as a component:


HTN, chronic pain, arthritis, COPD, diabetes,
Psychosocial stressors:

Family, Work, Stress, Depression (men less likely to discuss
this)
http://www.cmellc.com/geriatrictimes/g010132.h
tml

http://geniusbeauty.com/wp-content/uploads/2008/03/longevity.jpg
http://www.womenshealth.gov/aging/images/sexuality.jpg
DESPITE THESE BARRIERS, OLDER
ADULTS STILL DESIRE PHYSICAL
INTIMACY
ADDRESSING SEXUALITY AND SEXUAL
DYSFUNCTION
AGRONIN, M. E. (2001). GERIATRIC TIMES.


previous level of sexual
activity,

health and sexual
interest of a partner, and

an individual's overall
physical health.
http://thesituationist.files.wordpress.com/2008/0
2/older-couple.jpg
Major predictors of sexual
interest and activity in
late life include:
A STUDY OF SEXUALITY AND HEALTH
AMONG OLDER ADULTS IN THE U. S.
Survey of 3005 respondents (M & F), 57 to 85 years of age:




Majority of older adults were engaged in spousal or other
intimate relationships and regard sexuality as an important
part of life
38% of men and 22% of women reported having discussed sex
with a physician since the age of 50.
In the preceding 12 months, 73% of those ages 57 to 64, 53% of
those ages 65 to 74 and 26% of those ages 75 to 85 said they
were sexually active.
Of those reporting good or excellent health, 81% of men
and 51% of women said they had been sexually active in the
past year compared to just 47% of men and 26% of women
reporting fair or poor health.
http://www.usatoday.com/news/health/2007-08-22-seniorstudy_N.htm
LINDAU, ET AL., (2007), NEJM



Sexual frequency and satisfaction are higher
among unmarried and dating (or engaged)
individuals than among those who are married.
Forty-eight percent of those who are single and
dating say they have intercourse at least once a
week, compared to 36 percent of those who are
married
Sixty percent of dating singles are satisfied with
their sex lives, compared to 52 percent of those
who are married.
American Association of Retired Persons. (2010). “Sex, Romance, and Relationships” Survey [online].
Accessed Sept 25, 2010. URL: http://www.aarp.org/relationships/love-sex/info-05-2010/srr_09.html.
AARP “SEX, ROMANCE, AND
RELATIONSHIPS” SURVEY
DATA COLLECTED IN 1999, 2004, AND
2010
AARP “SEX, ROMANCE, AND
RELATIONSHIPS” SURVEY
DATA COLLECTED IN 1999, 2004, AND
2010


Older adults, want health care providers to know
that ‘sex was not just for the young’ and to
promote an open, accepting environment in
which sexual issues could be discussed.
Of those older adults who are single and in a
sexual relationship, only 12% of men and 32% of
women reported using protection.

Which leads to a discussion about RISK…

Risky behaviors are not limited to the younger
generations:

Multiple sex partners (e.g. “Condo Cowboys”)

Condoms: misperception of “risk” and erectile
dysfunction

IV drug use

Changing social status (divorce, widowed)

The internet
Bodley-Tickell, A. T., Olowokure, B., Bhaduri, S., White, D. J., Ward, D., Ross, J. D., Smith,
G., Duggal, H. V. & Goold, P. (2008). Trends in sexually transmitted infections (other than
HIV) in older people: Analysis of data from an enhanced surveillance system. Sexually
Transmitted Infections, 84, 312-317.
SEXUALLY TRANSMITTED INFECTIONS
(STIS) IN THE OLDER ADULT POPULATION
HIV: ASSOCIATED TRANSMISSION RISKS IN
OLDER ADULTS
SAVASTA, A. M. (2004). J ASSOC OF NURSES IN AIDS CARE.
Baby Boomers – Making Waves:
 “The aging Baby Boomer aggregate between the
ages of 40 and 49 years old are twice as likely to
have had more than five sex partners in their
lifetime than those between the ages of 50 to 59.”


(Binson, Pollack, & Catania, 1997).
“Sexual attitudes and behaviors of the Baby
Boomer generation will not change dramatically,
and those individuals will continue to remain
sexually active into their later years.”

(Masters & Johnson, 1966; Tichy & Talashek, 1992).
SEX AND THE ‘RECENTLY SINGLE’:
PERCEPTIONS OF SEXUALITY AND HIV RISK
AMONG MATURE WOMEN AND PCPS.
GRANT, K. & RAGSDALE, K. (2008). CULTURE, HEALTH, AND
SEXUALITY



“Age and ethnic group comparisons with the mature
women suggest that younger and African-American
women reported higher HIV and STI risk perception
than older and White women.”
Sixty-four percent of mature women (ages 45-68)
believed that they were at-risk for HIV and other
STIs.
In contrast, physicians considered “younger patients
most at-risk and that risk declined with patients'
advancing age and with female status.”
WHERE’S THE DATA?
STIS IN THE OLDER ADULT

What percentage of people over 65 are diagnosed
with a new STI each year?

Answers to these questions are difficult to ascertain
as there is a dearth of data.

CDC often groups HIV infection rates as >50 years
old.

In Europe, older adult data was grouped age 45 and
up.
HIV INFECTION IN THE ELDERLY




Of new HIV/AIDS cases reported to the CDC in 2005, over
15% were in persons 50 years and older while nearly 2% of
new diagnoses were in patients over 65 years of age.
Between 2001 and 2005, the estimated number of AIDS
cases by age of diagnosis had risen by nearly 40% in
persons 50 years and older.
During the same time period, the number of persons 50
years and older living with AIDS had doubled, and by the
end of 2005, this age group represented close to 30% of the
total US population living with AIDS.
Kirk and Goetz (2009) estimate that “by 2015, 50% of HIVinfected individuals in the United States are likely to be
aged 50 and older.”
Centers for Disease Control and Prevention. 2006. HIV/AIDS Surveillance Report, 2005 [online].
Accessed Sept 27, 2010. URL: http://www.cdc.gov/hiv/topics/surveillance/resources/reports/.
Kirk, J. B. & Goetz, M. B. (2009). Human immunodeficiency virus in an aging population, a
complication of success. Journal of the American Geriatric Society, 57(11), 2129-2138.
NGUYEN, N. & HOLODNIY, M. (2008)
HIV AND OLDER MINORITY WOMEN

Twenty percent of all women ever diagnosed with the
disease are Latina and 5.5% of Latinas infected with the
virus are older. The number of diagnosed infections is
increasing in older women, including Latinas, in spite of
recent declines in infection rates with younger populations.


Beaulaurier, R. L., Craig, S. L. & De La Rosa, M. (2009). Older Latina women and HIV/AIDS:
An examination of sexuality and culture as they relate to risk and protective factors. Journal of
Gerontology and Social Work, 52(1), 48-63.
Despite African Americans making up 11% of all older
women in the United States, in 2001, they accounted for
more than 50% of AIDS cases among older women and
more than 65% of HIV cases among older women.

Winningham, A., Corwin, S., Moore, C., Richter, D., Sargent, R. & Gore-Felton, C. (2004). The
changing age of HIV: Sexual risk among older African American women living in rural
communities. Preventative Medicine, 39(4), 809-814.

Older women (and men) are less likely to be
tested for and/or diagnosed with HIV, because:

presenting symptoms can mimic “common” complaints
of the older adult: fatigue, weight loss, dementia, skin
rashes, and swollen lymph nodes

providers do not perceive population to be “at risk”

older adults do not perceive themselves to be “at risk”.
Goodroad, B. K. (2003). HIV and AIDS in people older than 50. A continuing concern.
Journal of Gerontological Nursing, 29(4), 18-24
http://www.hivwisdom.org/facts.html
WHY ARE THE NUMBERS OF OLDER
ADULTS WITH HIV AND AIDS
INCREASING?

Once diagnosed, older adults face the following
complications:

Clinical Trials, studying safety and efficacy of HIV
medications, typically have NOT included
participants >65 years old

Multiple co-morbidities

Polypharmacy + HIV meds =  adverse drug events

Disease course is accelerated
Goodroad, B. K. (2003). HIV and AIDS in people older than 50. A continuing
concern. Journal of Gerontological Nursing, 29(4), 18-24.
Nguyen, N. & Holodniy, M. (2008). HIV infection in the elderly. Clinical
Interventions in Aging, 3(3), 453–472.
HIV: A MORE COMPLICATED
DISEASE COURSE
RESEARCH, EDUCATION AND PREVENTION
OF STIS IN THE OLDER ADULT


In health care, funding for research, education
and public health interventions is driven by
“perceived” need.
Until recently, increasing rates of STIs in older
adults has been a “silent” epidemic.
Sex and Seniors Video:
http://www.youtube.com/watch?v=IlJ9DmfluFk

THE HEALTH CARE PROVIDER (HCP)
SEX AND OLDER ADULTS

How do our perceptions
impact on our practice
as HCPs for the older
adult patient?

What do you think of
when you view these
pictures?

What health issues would
you have on your mental
list of “things to address”?
BARRIERS IN THE HEALTH CARE
SETTING

Health Care Provider

Discomfort and/or embarrassment

Personal beliefs (religious, cultural, etc…)

Minimal topic-specific education

Lack of time requiring “prioritizing” of health issues that
“matter more”

The Medical Model focuses on dysfunction of a system

Sexuality and sex are more than just the penis and vagina
BARRIERS IN THE HEALTH CARE
SETTING

Patient

Discomfort and/or embarrassment

Personal beliefs

Lack of knowledge


Cohort effect
Community vs. Long Term Care dwelling
A CASE STUDY:
MR. SMITH AND THE “SYNCOPAL
EVENT”

AS, 92yo WM

Assisted Living Facility

Syncopal Event

Gold-standard workup

The final “reveal”
THE HEALTH CARE PROVIDER
WHAT DO CAN WE DO?




Start the process by assessing our own values and
feelings and then determine how these influence the
work that we do and environment we create in the
“patient - HCP” relationship.
Incorporate sexual health history into assessment.
Do we initiate the discussion? Or do we allow the
patient to ask?
EDUCATE! EDUCATE! EDUCATE!
THE HEALTH CARE PROVIDER
WHAT DO CAN WE DO?

Safe Sex


How would you feel about educating a 70 year old
Widower on condom use? HIV testing? Dental dams?
Better sex
Are you able/comfortable with giving a 79 year old,
post menopausal woman advice on how to improve
her sex life with her current partner?
 Types of lubrication, sex toys, positions/methods of
sexual expression that account for a less-abled
physical status.

PATIENT REFERENCES

Books

Dr. Ruth “Sex after 50”

Robert Butler “The New
Love and Sex after 60”

Robert Wolley “Seniors in
Love”

Ruth Jacobs “Be an
Outrageous Older Woman”
WEBSITES - INFORMATION FOR THE PATIENT
AND THE

AARP

http://www.aarp.org/



2000 Sex Survey
HIV over 50
HIV




HEALTH CARE PROVIDER
http://www.hivwisdom.org/
http://www.nia.nih.gov/HealthI
nformation/Publications/hivaids.htm
http://hab.hrsa.gov/publications
/hrsa201.htm
Sue Johanson

http://www.talksexwithsue.com/
index2.html




Dr. Ruth

http://love.ivillage.com/author/b
io/0,,prtr,00.html
http://www.seniorjournal.com/S
ex.htm
Institute on Aging


www.seniormatch.com
Senior Journal on Sex and
Senior Citizens

http://www.nia.nih.gov/
Older Adult LGBT



Dating
http://sageusa.org/index.cfm
Sexual Health

http://sexhealth.healthology.co
m/focus_webcast.asp?f=sexual_
health&c=healthyaging_sextab
oo#
WEBSITES - INFORMATION FOR THE PATIENT
AND THE

Holistic Wisdom - Senior
sex


http://www.holisticwisdom
.com/senior-sex.htm
Mayo Clinic - Senior Sex


HEALTH CARE PROVIDER
http://www.mayoclinic.co
m/health/seniorsex/MC00057
NY Times

http://www.nytimes.com/2
007/02/14/nyregion/14sex.
html

Sex and Arthritis

http://arthritis.about.com/
od/sex/Sex_And_Arthritis_
Sexuality_Intimacy_Arthr
itis_And_Love_Dating.ht
m
HUMOR – VIVA VIAGRA!
http://letustalk.files.wordpress.com/2008/07/viagra.gif
http://marbella.to/humour/sep00/viagra.jpg
Thank you for your time and attention!
REFERENCES









American Association of Retired Persons. (2010). “Sex, Romance, and Relationships”
Survey [online]. Accessed Sept 25, 2010. URL: http://www.aarp.org/relationships/lovesex/info-05-2010/srr_09.html.
Agronin, M. E. (2001). Addressing Sexuality and Sexual Dysfunction. Geriatric Times, 2 (1
Beaulaurier, R. L., Craig, S. L. & De La Rosa, M. (2009). Older Latina women and
HIV/AIDS: An examination of sexuality and culture as they relate to risk and protective
factors. Journal of Gerontology and Social Work, 52(1), 48-63.
Binson, D. B., Pollack, L. & Catania, J. A. (1997). AIDS related risk behaviors and safer sex
practices of women in midlife and older in the United States: 1990-1992. Health Care for
Women International, 18, 334-354.
Bodley-Tickell, A. T., Olowokure, B., Bhaduri, S., White, D. J., Ward, D., Ross, J. D., Smith,
G., Duggal, H. V. & Goold, P. (2008). Trends in sexually transmitted infections (other than
HIV) in older people: Analysis of data from an enhanced surveillance system. Sexually
Transmitted Infections, 84, 312-317.
Centers for Disease Control and Prevention. 2006. HIV/AIDS Surveillance Report, 2005
[online]. Accessed Sept 27, 2010. URL:
http://www.cdc.gov/hiv/topics/surveillance/resources/reports/.
Goodroad, B. K. (2003). HIV and AIDS in people older than 50. A continuing concern.
Journal of Gerontological Nursing, 29(4), 18-24.
Grant, K. & Ragsdale, K. (2008). Sex and the 'recently single': Perceptions of sexuality and
HIV risk among mature women and primary care physicians. Culture, Health, and
Sexuality, 10 (5), 495-511.
Hajjar, R. R. & Kamel, H. K. (2003). Sexuality in the Nursing Home, Part 1: Attitudes and
Barriers to Sexual Expression. Journal of the American Medical Directors Association, 4
(3), 152 -156.
REFERENCES









Kirk, J. B. & Goetz, M. B. (2009). Human immunodeficiency virus in an aging population, a
complication of success. Journal of the American Geriatric Society, 57(11), 2129-2138.
Lindau, S. T., Leitsch, S. A., Lundberg, K. L., & Jerome, J. (2006). Older women’s attitudes,
behavior, and communication about sex and HIV: A community-based study. Journal of
Women’s Health, 15 (6), 747-753.
Lindau, S. T., Schumm, L. P., Laumann, E. O., Levinson, W., O’Muircheartaigh, C. A. &
Waite, L. J. (2007). A study of sexuality and health among older adults in the United
States. The New England Journal of Medicine, 357, 762-774.
Masters, W. & Johnson, V. (1966). Human Sexual Response. Boston: Little, Brown.
Nguyen, N. & Holodniy, M. (2008). HIV infection in the elderly. Clinical Interventions in
Aging, 3(3), 453–472.
Savasta, A. M. (2004). HIV: Associated transmission risks in older adults – An integrative
review of the literature. Journal of the Association of Nurses in AIDS Care, 15 (1), 50-59.
Tichy, A. M. & Talashek, M. L. (1992). Older women: Sexually transmitted diseases and
acquired immunodeficiency syndrome. Nursing Clinics of North America, 27, 937-950.
Winningham, A., Corwin, S., Moore, C., Richter, D., Sargent, R. & Gore-Felton, C. (2004). The
changing age of HIV: Sexual risk among older African American women living in rural
communities. Preventative Medicine, 39(4), 809-814.
Zelenetz, P. D. & Epstein, M. E. (1998). HIV in the elderly. AIDS Patient Care and STDs,12(4),
255-262.