Health literacy and older adults

Despite the dominant assumption that older people are asexual or lacking sexual desires,^{Reference Bauer and Geront21,Reference Doll22} older adults are sexually active in later life.^{Reference Somes and Donatelli17} Indeed, it is important to them to be so^{Reference Gott and Hinchliff15} and, as discussed above, it is evident that older adults are engaging in a wide range of sexual relationships and experiences.^{Reference Gott, Rogstad, Riley, Ahmed-Jushef and Green23} However, available research indicates that there is a distinct lack of sexual health information targeted towards and provided for the older adult population.^{Reference Slinkard and Kazer24} This lack of information can be seen as a substantial contributory factor to the sexual risk-taking behaviours observed in this population. Further to the lack of information, older people are also not seen as a priority group from the perspective of the NHS and local DISH services. While the sexual health status of younger adults is a healthcare, social and research priority, it remains a largely ignored aspect of ageing.^{Reference Abel and Werner25} Despite a life-course approach,²⁶ the priorities of these services are younger adults who are seen as the more ‘at-risk’ group. This suggests a disparity between research findings and policy for clinical practice. Whilst numerically this is correct, a small but significant amount of those older adults who were tested have returned positive results. This could indicate one of two things: those older adults who put themselves at risk are aware of this and go for testing, or that there are more widespread issues regarding prevalence rates of STIs within the older cohort that are not observed due to lack of self-referral to DISH clinics. In both instances, increasing a targeted health literacy campaign towards older adults and improving the accessibility of services would benefit their health and wellbeing. To do this, however, it is important to address negative attitudes and misconceptions.^{Reference Duerson, Thomas, Chang and Stevens27–Reference Nash, Stuart-Hamilton and Mayer32}

Social and demographic changes in sex, ageing and societal responses

During the last five decades, there have been significant social and demographic changes within Britain, such as increased longevity, enhanced recognition of civil and political rights and increased divorce rates. These have, in turn, shifted attitudes towards sexual relationships, sexual activity and household patterns of intimacy. Those older adults who are widowed are no longer necessarily resigned to a single life following the death of a spouse, but are instead becoming more likely to seek and find out other people for new relationships, both sexual and for companionship.^{Reference Smith and Christakis33} In doing this, they are potentially engaging in sexual activity with a new partner about whose sexual history they may know very little. The desire for company and intimacy may impact on the decision-making process about whether to practise safe sex or not – requesting this highly sensitive information from a sexual partner may be seen as a signal of distrust and potentially compromise the relationship.^{Reference Crosby, Shrier and Charnigo34} Furthermore, initiating discussions about safe sex and condom use and indeed accessing STI screening were not familiar practices prior to the onset of the HIV epidemic in the 1980s.^{Reference Schick, Herbenick and Reece35}

A similar issue is that of increased longevity and the associated dissolution of ‘romantic relationships for life’,^{Reference Schick, Herbenick and Reece35} in parallel with increases in divorce rates. It is also of note that this phenomenon is not exclusive to the lives of young people, with increasing divorce rates in the over-50s.³⁶ In introducing extramarital relationships, there is an increased risk of STI transmission should unprotected sex be engaged in by all parties, especially if the third party is also engaged in another relationship. It is the change in these dynamics that opens up the risk of STI transmission when combined with the already identified low levels of health literacy^{Reference Slinkard and Kazer24} and targeted information campaigns. The risks of multiple partners and of condom-less sex have not been made apparent, especially within the heterosexual community where condoms were seen very much as a strategy for preventing unwanted pregnancy (no longer a possibility post-menopause) and where STI/HIV transmission was perceived and falsely depicted as a homosexual problem.^{Reference Tan, Wong and Chan37}

It has already been established that one of the largest expanding groups of older adults reporting positive results on STI screening are MSM7 and this is true for both younger and older adults. This can be partly traced to the criminalization of homosexuality in the UK prior to legal reform in 1967. From this point, although still not socially acceptable, it was no longer a criminal offence that could cause incarceration and create a criminal history.^{Reference Fish38} Although the sexual lives of MSM were no longer formally policed by the State, the shadow of criminalization may continue to hinder older LGB adults from accessing and discussing their sexual lives with health professionals.^{Reference Willis, Maegusuku-Hewett, Raithby and Miles14,Reference Fish38,Reference Stonewall39} From this point through to wider social acceptance in the 1990s and 2000s, the incidence of STIs in MSM has continued to rise.5 There has been sustained campaigning and awareness-raising within gay and bisexual communities about the transmission of STIs and notably of HIV. These campaign efforts are competing with increased access to antibiotics, the availability of antiretroviral combination therapy for people living with HIV and that the gay community values sex to such a great degree that sexual pursuits, even towards old age, are considered imperative which may compromise safe sex messages.^{Reference Jacobs, Kane and Ownby40} More engagement is clearly needed, targeted not only at MSM but also specific groups. Campaigns targeted at MSM accessing commercial social venues and clubs are unlikely to be effective in addressing the need of older men in the same way that a general population campaign is unlikely to reach the older adult cohort.

Hidden diagnoses of STIs in older adults

There are several reasons why STIs can be overlooked medically, with many related to the prototypical processes of ageing. In women, symptomatology of infection includes cramps, bloating and vaginal bleeding, all of which are associated with menopause^{Reference Pearline, Tucker and Yuan41} and can be overlooked by both the older adult and the medical professional.^{Reference Sherrard and Wainwright42} Confusion can occur also around causes of genital irritation such as genital ulcers or primary chancroid, where other more common complaints for older adults may be mistaken, for example urinary tract infections (UTI).^{Reference Wilson43} Engaging in conversations with older adults about their sexual activity could be one way of establishing possible causes and entering into dialogues about sexual health practices. To do this, however, misconceptions of older people's sexuality and overcoming the embarrassment of discussing these, from the perspective of both the older patient and the practitioner, have to be overcome. Increased awareness within the medical and research fraternities need to be fostered, developing specialist targeted campaigns designed to engage specifically with older adults.

Research indicates that STIs can influence not only reproductive capacity but also brain function, especially cognition,^{Reference Mehrabian, Raycheva, Petrova, Tsankov and Traykov44,Reference Wendelken and Valcour45} mimicking more common causes of dementia such as Alzheimer's disease. It is thus evident that medical professionals need to be more open to the possibility that an older adult may be presenting with a STI, in order to facilitate its effective treatment and to reduce the risk to partners. The correct diagnosis and successful treatment of STIs in older adults could also prove to be cost saving, where potentially expensive support costs could be alleviated through the successful treatment of the infection. A prime example of this is syphilis, as its tertiary symptomatology may be reversible/treatable if caught at early or latent stages, or stoppable thereafter.^{Reference Arnold and Kumar46,Reference Parsonage, Wilkins, Snowden, Issa and Savage47} This may add to the argument that testing should be made more accessible for older adults, with specialist clinics/times available for their sole use in the same way that there is for younger ‘at-risk’ groups.

Barriers to dialogue, diagnosis and treatment

Despite living through a period of significant legal and social reform in the 1960s and 1970s, older people may be reluctant to discuss aspects of their sexual lives and histories in comparison with younger people.^{Reference Bulford and Singh13,Reference Slinkard and Kazer24} Similarly, differences between generations may prevent older adults communicating their concerns regarding sexual health, activity and wellbeing to younger adults.^{Reference Rivers48} Older adults are unlikely to engage in such conversations with their adult children, or indeed other members of their family, because of (i) wider societal beliefs of older adults as lacking sexual interest and desires, and (ii) the highly sensitive and stigmatized nature of discussing personal and intimate details with younger generations. This discomfort is not limited to family members, as older adults and non-specialized doctors share the same social anxieties with engaging in open and frank discussion about sexual health and activity.^{Reference Jeffers and DiBartolo49} This may lead to skirting around sexuality-related issues and, where symptoms are presented, preferring to test, diagnose and treat for other ‘more likely’ causes based on chronological age.^{Reference Duerson, Thomas, Chang and Stevens27,Reference Sherrard and Wainwright42}

Feelings of shame and embarrassment can accompany self-reports of sexual history.^{Reference Sherrard and Wainwright42} Arguably, this increases the responsibility of healthcare professionals to initiate discussions about sexual health, activity and wellbeing in their interactions with older adults. While older adults report a willingness to discuss their sexual lives with medical professionals, they may not have the vocabulary or the confidence in their GP to encourage them to discuss psychosexual problems or STI-related symptoms in an open manner.^{Reference Bulford and Singh13} Social discomfort may be shared by medical professionals who may be reluctant to initiate discussions about sexual history with older patients in fear of causing personal offence, evoking responses of embarrassment, or because of negative feelings of disgust associated with dominant discourses of ageing and sex.^{Reference Somes and Donatelli17} Sherrard and Wainwright^{Reference Sherrard and Wainwright42} contend that GPs are ideally situated as primary health professionals for screening older patients’ sexual histories and identifying STI symptoms. Failure to diagnosis STIs can delay the treatment of bacterial infections, or worse, result in misidentification of manifestations of HIV as being ageing-related symptoms.^{Reference Sherrard and Wainwright42}

Heterosexist attitudes (the prevailing assumption that all older people live heterosexual lives) may blinker health and social care staff from appropriately responding to LGB-identifying older adults, or recognizing adults in same-sex relationships, for example MSM.^{Reference Dentato, Orwat, Spira and Walker50} The practice of care workers providing support to older people in residential and nursing settings may be confounded by assumptions of both asexuality and heterosexuality. Both social discourses can prevent staff from discussing sexual histories with residents, resulting in this information being absent from residents’ care plans.^{Reference Willis, Maegusuku-Hewett, Raithby and Miles14,Reference Jeffers and DiBartolo49}

Lack of opportunities to discuss sexual health with GPs and other primary health professionals prevents older adults from receiving information and education on safer sex practices and limits knowledge of professionals about their patients’ sexual health.^{Reference Slinkard and Kazer24–Reference Abel and Werner25,Reference Sherrard and Wainwright42} This can limit some older groups’ understandings of HIV transmission; for example, older women may be unfamiliar with condom use and HIV risks associated with unsafe sex.^{Reference Neundorfer, Britton and Lynch51} In turn, this can lead to inconsistent or low condom use among older adults.^{Reference Smith and Christakis33} Universal sexual health screening of older adults would place new demands on healthcare services especially in terms of cost,^{Reference Matiluko and Crystal52} but increased attention to possible STI symptoms is vital.^{Reference Holden and Trachtman29} Health professionals need to be mindful of older adults’ potential exposure to unsafe sex and include discussions of sexual practices in routine health assessments.^{Reference Fox-Seaman28,Reference Holden and Trachtman29,Reference Minicucci, Vieira, Oliviera and Marques53,Reference Poggiali, Pisani, De Padova, Ghilardi and Bilenchi54}