Clinicians and researchers pay less attention to the sexual health needs of older adult than other ages groups. Evidence suggests this population’s risk of sexually transmitted infections (STIs) is climbing.1
Surveillance data from the CDC revealed a 27% increase in U.S. adults older than age 45 years diagnosed with gonorrhea, syphilis, and chlamydia between 2016 and 2018. 1-3 The CDC’s surveillance data from 2020 found an overall increase in gonorrhea cases of 45% from 2016 and a 52% increase in syphilis cases in that same period. Overall, chlamydia cases were down 1.2%.2
Do Not Ignore Older Patients
Middle-age and older women and men often are sexually active. Sometimes, they are unaware of their risk of infection because this topic rarely is discussed in their primary care visits.
“Providers should not assume that because a woman is beyond fertility years that she does not have sex,” says Patricia Kissinger, PhD, BSN, MPH, a professor of epidemiology Tulane University School of Public Health and Tropical Medicine in New Orleans.
OB/GYNs and sexual health clinicians should assess their older patients for STI risk. They could ask if the patient is engaging in condomless sex with a partner. Patients also should be assessed for HIV risk.
“There may be a need for them to go on PrEP [pre-exposure prophylaxis] because we’re seeing more older women fit in that bucket,” Kissinger says. “If they’re having sex with a bisexual partner, or a partner who is drug-using and is at higher risk for HIV, then you want to assess for that.”
Although the CDC and most public health departments focus on STIs among people younger than age 25 — since they carry a disproportionate share of STI cases — clinicians need to consider the possibility that their older patients also could be infected or at risk of infection.
“Sexual health goes on throughout your life,” Kissinger says. “With older adults, we don’t normally think of them as at risk for STIs, but we’re seeing outbreaks of STIs in nursing homes or retirement homes.”
Part of this increase in transmission is driven by the use of Viagra and other medications that enable people to engage in sexual activity for longer. “Also, as the population is aging in the U.S., sexuality doesn’t finish. We see wide ranges of prevalence rates from none to up to 20%, depending on the context of what’s going on with those elders,” Kissinger says.
Kissinger’s research is a systematic review of literature on STIs in the United States, including chlamydia, gonorrhea, and syphilis in older adults. A second review paper addressed the burden of trichomoniasis among older adults.4
Older women and men may be less likely to use condoms because of the reduced danger of HIV infection, which can be treated as a chronic illness. Also, women who no longer have to worry about pregnancy may be less inclined to ask partners to use condoms.
“They may relax their condom usage, and that’s when they get sexually transmitted infections,” Kissinger says. “Much like women might get on contraception and stop thinking about condom use because they’re avoiding their biggest concern of pregnancy.”
Some STIs Remain Dormant
Trichomoniasis is different because the rates of infection traditionally have been higher in older women. “Women can have that infection for a long time,” Kissinger says.
The protozoan parasite Trichomonas vaginalis can remain dormant and asymptomatic for years. The parasite could cause problems when the woman is older, so it is best to screen women and treat their infection, Kissinger adds.
With chlamydia, infection rates tend to diminish after age 24 years, possibly due to innate immunity fighting off the infection. “Some of these older folks may not have this immunity anymore, or they never had it, and that’s why we’re seeing those infections in older people,” Kissinger says. “It lies dormant.”
While screening for STIs has become a lower priority in the COVID-19 era, the current environment of rising STI rates shows why screening remains essential — and why older women should not be ignored.
“We need to debunk the myth that older people don’t have sex,” Kissinger says. “Understand their sexual behaviors and their protective behaviors.”
Clinicians can ask their older patients these questions:
- Do you have multiple sexual partners?
- Do your male partners use a condom?
- Have you been exposed to anyone with an STI?
If they answer yes to any of these questions, then they should be screened for STIs.
The CDC recommends general STI screening for women who are sexually active and younger than age 25 years, or who are older and in a high-risk group. But since the major health problems from STIs occur to women, including ectopic pregnancy and pelvic inflammatory disease, then more extensive screening could be important.
Older patients may not know as much about STIs as younger patients or be comfortable asking for information.
“Older women, particularly women in their 60s, may not have had the advantage of good sex education, and they might not know about STIs,” Kissinger says. “You see a lot of marriages dissolve when women are in their 40s or 50s, and they are not prepared for dating.”
Clinicians may ask these women if they have any symptoms, such as a vaginal discharge that is frothy or greenish and maybe itches. They could be experiencing irritation and painful sexual intercourse. Any of these symptoms indicate the woman needs to be screened for STIs.
Treatments for most of these infections are effective and inexpensive, so it is important to screen patients and provide treatment as needed.
“It’s the call of the provider, but they should get it on their radar to think about because if you don’t think about it, you won’t do it,” Kissinger says.
REFERENCES
- Htet KZ, Lindrose AR, O’Connell S, et al. The burden of chlamydia, gonorrhea, and syphilis in older adults in the United States: A systematic review. Int J STD AIDS 2023;9564624221149770.
- Centers for Disease Control and Prevention. Sexually transmitted diseases (STDs) data & statistics. Page last reviewed Aug. 22, 2022.
- Levine B. STDs rise sharply among older Americans. Everyday Health. Oct. 17, 2019.
- Lindrose AR, Htet KZ, O’Connell S. Burden of trichomoniasis among older adults in the United States: A systematic review. Sex Health 2022;19:151-156.
Clinicians and researchers pay less attention to the sexual health needs of older adult than other ages groups. Evidence suggests this population’s risk of sexually transmitted infections is climbing.
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