Sexually Transmitted Diseases in the Aging Population
Key words: Sexually transmitted diseases (STDs) in older adults, sexual activity in older adults, HIV, chlamydia, gonorrhea.
Healthcare providers often view sexually transmitted diseases (STDs) as infections contracted by younger adults during sexual contact with infected persons. This is based on the pervasive assumption that older adults are less sexually active than their younger counterparts; however, since 2000, the number of STDs in the US population has steadily increased among persons aged 50 years and older.1,2 Chlamydia, gonorrhea, and HIV are among the most frequently reported STDs in this age group and include both newly acquired infections and residual complications.1,2 The Centers for Disease Control and Prevention (CDC) estimated that, in 2005, 15% of new HIV/AIDS infections and 24% of persons living with HIV/AIDS involved those older than 50 years; the latter statistic represents an increase from 17% in 2000.1 In 2010, the US Census Bureau estimated that 32.1% of Americans were aged 50 years and older, which equates to approximately 99,048,838 older adults.3 Despite these facts, few research studies exist regarding STDs in the aging population.4-10 One 2007 study reviewed 143 clinical trials targeting risky sexual behavior.7 This study found that 72.7% of the STD risk-reduction clinical trials excluded participants older than 50 years and 88.8% excluded those older than 65 years. Yet people do not cease engaging in sex as they age. A University of Chicago study that surveyed 3005 persons aged 57 to 85 years found that 73% of those aged 57 to 64 years, 53% of those aged 65 to 74 years, and 26% of those aged 75 to 85 years are sexually active.11 This review discusses the three most common STDs in older adults (>50 years), which include chlamydia, gonorrhea, and HIV; explains the common misconceptions held by providers and patients regarding STDs; describes STD risk factors and prevention measures; and provides suggestions for obtaining a sexual history.
Misconceptions Regarding STDs in Older Adults
Healthy People 2020 continues to recognize HIV and STDs as problems in the United States and continues to make efforts to reduce this problem.12 Prevention strategies for older adults in the primary care setting often are not aimed at HIV or STDs, and sexual behaviors tend to be talked about least. This may be partly because practitioners think sexual activity is infrequent in older patients and partly because older adults may have been socialized to avoid discussing it. Even patients who are asymptomatic and no longer sexually active, however, may have contracted an STD years earlier but were never tested and remain unaware they have such a disease. Providers may not recognize signs and symptoms of STDs in older adults or may attribute symptoms to a different cause, which can delay diagnosis and treatment. This delay not only increases the potential for complications, but also increases the risk of transmission to sexual partners,5 as demonstrated by the case scenario that follows.
A 70-year-old white man visited his primary care provider (PCP) for symptoms of weight loss and fatigue. He reported a weight loss of 20 lb and increased fatigue over the past 6 months. After undergoing neurologic testing, psychiatric testing, and routine laboratory testing to rule out cancer and thyroid disease, he received a diagnosis of Alzheimer’s disease. When the patient needed a postoperative blood transfusion several years later, his activated Power of Attorney consented to an HIV test, and the patient was found to have AIDS-related dementia, rather than Alzheimer’s disease. The PCP, however, had never taken the patient’s sexual history, assuming he was not at risk for an STD because of his age.
As this case scenario shows, such a misdiagnosis can put a patient at risk for early death from lack of treatment and put both healthcare professionals and family members at risk for contracting the disease. To avoid situations like this, providers need to be aware of the most commonly observed STDs in older adults and understand how these STDs manifest in this population so that they can make an accurate and timely diagnosis. What follows is a review of some of the most common STDs in older adults.
Most Common STDs in Older Adults
Chlamydia and gonorrhea are among the most commonly reported STDs in the United States, including among older adults. Both STDs are bacterial infections that can be treated easily with antibiotics. However, many people do not know they have these diseases because they are asymptomatic or do not have their symptoms evaluated. Yet when STDs remain untreated, they can cause many harmful complications, including cancer and facilitation of HIV transmission in all patients, as well as fetal, perinatal, and reproductive health problems in younger
Chlamydia is caused by the bacterium Chlamydia trachomatis. Women are often asymptomatic, but symptoms may include abnormal vaginal discharge, dysuria, abnormal vaginal bleeding, and pelvic pain.13 Men may report mucopurulent or purulent discharge from the urethra and burning upon urination, but many men may be asymptomatic.13 Chlamydia is a common cause of cervicitis in women and urethritis in men.13 Both sexes may experience chlamydial conjunctivitis, which can cause red and sticky discharge from one or both eyes and swollen eyelids. In some cases, the cornea may be involved. Therefore, an eye examination is a crucial part of the examination and can aid in making the diagnosis, but laboratory studies are needed to make a definitive diagnosis.14 This may include an antigen test, a urine test, or a swab culture test. When a swab culture test is used, the swab is inserted into the cervix in women and the end of the penis in men to obtain a bodily fluid sample.14
Although consequences of untreated chlamydia include sterility in persons in their reproductive years, this infection can also cause complications such as Reiter’s syndrome (a type of arthritis caused by the body’s reaction to bacterial infection), which can affect persons of any age. In addition, an association between chlamydia and cervical cancer risk has been found, and it has been suspected that chlamydia may prolong human papillomavirus (HPV).15 However, HPV appears to be one of the least common STDs in older patients. One study showed an HPV prevalence of only 6% among women aged 57 to 85 years.16 In contrast, since 1994, chlamydia has made up the largest proportion of all STDs reported to the CDC.17
Gonorrhea is caused by the bacterium Neisseria gonorrhoeae, which can grow in the cervix, uterus, fallopian tubes, urethra, mouth, throat, eyes, and anus. Symptoms can include urethritis in men and slight discharge and dysuria in women. However, many infections among women do not produce symptoms until complications have occurred, such as pelvic inflammatory disease.13 Like chlamydia, gonorrhea can also cause eye problems for both sexes, including eye pain, sensitivity to light, and pus-like discharge from the affected eye(s). Laboratory assessments are needed to make a definitive diagnosis. These tests may include culturing the bacteria, staining tests to detect the presence of the bacteria, or urine tests to detect the presence of gonorrheal DNA.18
The CDC estimates that more than 700,000 persons in the United States each year become infected with gonorrhea.19 However, only about half of these cases are reported to the CDC because not all states are required to report these statistics.
HIV is an infection that kills cells of the immune system, particularly the CD4+ T-cells (T-lymphocytes).13 Symptoms may start within 2 to 4 weeks after exposure and can include fever, chills, rash, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, and ulcers in the mouth.20 However, many individuals only start to feel ill when their HIV infection progresses to AIDS.20
The number of older adults living with HIV/AIDS has increased because patients with HIV are living longer due to better antiretroviral therapy and because there are more newly diagnosed infections in persons older than 50 years.1 Approximately 11% of new HIV infections occur in adults aged 50 years and older,21 and these patients may have the same risk factors for HIV infection and other STDs as younger adults. It has been reported that individuals with STDs are at least two to five times more likely to acquire HIV if exposed to this virus.22 This is because STDs cause inflammation, which increases the concentration of cells in genital secretions that can serve as a nidus for HIV infection.
Provider’s Role In Diagnosing STDs in Older Adults
Many healthcare professionals have misconceptions that older or elderly persons are not sexually active or assume they are in a heterosexual monogamous relationship, when they may truly be at risk for STDs.4 Sexuality and emotional health are part of a complete medical history; however, sexual histories in older patients are often not taken or are incomplete, partly because the provider feels anxious or uncomfortable discussing sexual issues compared with discussing less sensitive issues, such as gastrointestinal or cardiovascular problems.23
To obtain an accurate sexual history from patients, PCPs must first identify their personal comfort level with discussing the topic. One way to become more comfortable includes having an awareness of one’s personal beliefs, behaviors, thoughts, and feelings regarding sexuality. This may be accomplished by attending professional educational sessions or by talking with peers regarding feelings about such discussions and approaches to obtaining a sexual history. The Table also provides some tips on how to discuss sexual matters with patients.
A complete sexual history should include information about sexual partners, physical signs or symptoms, problems, and overall satisfaction.4 Sexually active patients should be asked if protection against STDs is being used. One qualitative study interviewing 519 PCPs found that 87% asked about sexual risks only when patients requested contraception.24 This approach excludes the older population completely. Healthcare professionals must also be aware that sexual abuse of older adults puts them at risk for STDs. Elder abuse is an underrecognized problem, and warning signs of sexual abuse in elders can include bruises around the breasts or genital area and unexplained STDs.25
Healthcare professionals may not be the only ones who have misconceptions about sexuality. Older adults may not believe they are at risk for STDs; however, it is estimated that the average person older than 50 years still engages in sexual activity two to four times per month.10 A study done from 1990 to 1991 using a national survey found that less than 4% of sexually active older adults with at least one risk factor for HIV infection had used condoms consistently in the preceding 6 months.10 It is important for older adults to understand that sexual activity includes anything that exposes them to bodily secretions. This includes vaginal or anal intercourse, performing or receiving oral sex, and masturbation.
The aging process also puts older adults at greater risk for STDs. The immune system declines as people age, making them more susceptible to infectious diseases. In older women, thinning of the vaginal walls after menopause can result in tears during sexual activity, facilitating disease transmission.4,10,26 In men, the aging process can result in sexual dysfunction. This is even more pronounced in patients with a chronic illness or those taking medications with sexual side effects. In men older than 60 years, the ability to ejaculate diminishes.27 The introduction of agents for the treatment of erectile dysfunction over the past 15 years may have made it easier for male patients to discuss sexual problem with their PCPs, leading to renewed sexual activity. The introduction of agents such as sildenafil into the primary care setting provides an opportunity for PCPs to ask their patients questions about their sexual history and address sexual issues, including STDs.
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Prevention of STDs
The ability to have meaningful sexual relationships is an important indicator of quality of life,28 but all patients should know that unprotected sexual activity is unsafe at any age. The need for condoms may not be realized when patients are past their reproductive years, have been in a lengthy monogamous relationship, or are unaware of the increase in risk if they enter a new sexual relationship after the death or divorce of a spouse. One national survey for at-risk patients older than 50 years found that this group was one sixth as likely to use condoms.29 Older adults, however, need to be as aware as the younger population of the importance of using condoms.30 Another survey done by the University of Chicago found that 60% of unmarried women aged 58 to 93 years did not use condoms the last time they had sex.31 A qualitative study done in 2004 focusing on semistructured interviews with 223 patients with gonorrhea found that most participants reported inconsistent or no condom use.32 Therefore, the PCP should ask all patients, regardless of age, about condom use and other prevention strategies (eg, abstinence, having only one sexual partner).
Testing for STDs
Many reasons exist for the lack of testing older adults for STDs, including HIV. These patients may not get tested because they do not have symptoms, do not consider themselves at risk, or believe they have partner(s) who are not infected with any STDs, which may not always be the case.33 Resources for testing may be limited, patients may not know where to go, testing sites may be inconveniently located, and financial or health insurance resources may be lacking. The stigma of having an STD and a lack of education may be contributing factors. Younger adults may be comfortable going to free clinics or Planned Parenthood locations for testing; however, the older adult may be unaware of or feel embarrassed to use these facilities. Senior centers rarely provide information regarding STD risk and testing.
Differences in racial and sexual perspectives also exist. Two studies done regarding sex, race, and STD diagnosis found that, most of the time, African Americans and women were more likely to get tested.34,35 Two other studies found that higher percentages of STDs were reported in older men than in older women.5,10 Xu and colleagues10 found that the percentage of gonorrhea cases diagnosed in men aged 50 to 64 years was 2%, but only 0.3% in women in the same age group. In this same study, gonorrhea was the second most common STD reported in men 50 years and older, whereas chlamydia was the second most common STD in women 50 years and older.10
Provider Discrepancies in Assessing Risk in Older Adults
Most people receive healthcare from a PCP, which can include family practice (FP) physicians, internal medicine (IM) physicians, certified nurse midwives (CNM), nurse practitioners (NP), or obstetrician-gynecologists (OB/GYN). PCPs spend a good amount of time with patients on preventative medicine, which is where most STD prevention, diagnosis, and treatment occur, and they are in a key position to affect patient behavior through effective risk assessment and prevention counseling.24 This focus on prevention provides an opportunity for PCPs to effectively help patients reduce risky sexual behaviors.
Screening recommendations are usually aimed at younger persons. According to the CDC, however, HIV screening recommendations include routine voluntary blood tests in all patients aged 13 to 64 years to prevent the 50% to 70% of new infections spread by persons unaware they are infected.1 Adults older than 64 years with risk factors should also be tested for HIV.
A qualitative study done in primary care settings in the United States interviewed 519 FP, IM, OB/GYN, CNM, and NP providers in Washington State via questionnaires.24 The goal was to describe current practices in STD/HIV services, including risk assessment, prevention counseling, and testing. The authors found that risk assessment practices differed among types of PCPs; IMs were least likely to use strategies to elicit concerns and identify STD risk.24 NPs and CNMs were most likely to ask patients specific STD risk questions on a routine basis. More than half (60%) of all PCPs were found to be universal counselors, but NPs were more likely to be holistic counselors than physicians of all types.24
Need for Better Public Education
Education regarding safe sex practices and STD risk factors is essential in the primary care setting to decrease the number of STD cases in older adults, but public education is also needed. Few public prevention and educational programs exist for older adults, and those that do exist are often aimed at younger high-risk groups.36 These programs do not adjust for older adults’ needs, and a more inviting way for older adults to receive education regarding these issues is required. One way to provide more information about STD risk is by disseminating this information through publications that target older adults, such as Reader’s Digest and AARP Magazine (known as Modern Maturity until 2002).8
Some states have taken the initiative to provide older adults with sexual education and resources. In 2007, New York City began handing out condoms and educational materials to senior centers and instructed all older adults to get tested for HIV as part of a routine check-up.37 Florida’s Senior HIV Intervention Project also distributes condoms and safe sex advice at Jewish community centers and assisted living facilities throughout the state.37 Educational programs and initiatives like these should be made available throughout the United States.
Safe sex practices need to be addressed with all patients who are sexually active. PCPs should underscore the fact that older patients are not immune to contracting STDs. Consistent and correct condom use is essential in the provider’s education of the patient, including appropriate use during oral sex. A 2009 study done in the United Kingdom used both qualitative and quantitative methods to identify potential intervention opportunities for secondary prevention among 223 patients aged up to 66 years who had previously received a gonorrhea diagnosis.32 The results showed good evidence that, with sexual health promotion interventions in clinical settings, patients can change risky sexual behaviors, such as by using condoms.32 PCPs should consider having condoms on hand in the office to distribute to patients who are at risk. PCPs should also use universal precautions during patient contact, to avoid personal risk and help reduce the risk of transmission to other patients.
In another study, done by Altschuler and colleagues,38 the authors focused on developing and implementing an HIV/AIDS educational curriculum for older adults. In this study, 249 adults aged 50 years and older were included based solely on age. They were surveyed regarding interest in attending a prevention and education program. The authors found that women were more likely to attend such programs. They also found that the likelihood of attending such programs decreased as age increased. Further, the more religious a person was, the more likely he or she was to attend an educational program.
Patients and providers may be unaware of the risk of STDs in older adults for several reasons, including misconceptions about sexual activity in this age group. It is important for healthcare professionals to be aware of the increasing number of older patients with STDs and the importance of obtaining an accurate and complete sexual history for patients of any age. Prevention and education regarding increased risk for STDs and safe sex practices that are geared toward older adults are also needed in PCP and public health settings to combat the increasing prevalence of STDs among older adults.
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The author reports no relevant financial relationships.
Address correspondence to:
Angela Purpora, FNP, APNP-BC
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