It takes two to tango: discussing sexual health with older patients in primary care

Sex can be good for us as we age and ongoing sexual activity is associated with health and wellbeing. Research also shows that people who continue to be sexually active in later life are more satisfied with their lives and have lower levels of depression. 

In recent times the issue of late-life sexual activity has been a “sexy” topic of interest in lay media, radio and in academic circles, including The Conversation.  Whilst it was once firmly fixed in the medical domain and the problems or issues associated with dysfunction and chronic disease, a growing body of evidence now emphasises its bio-psycho-social aspects and the redefinition of what sexual expression means to older people.  We are gradually moving away from the biomedical definition of sex as intercourse, towards a more nuanced view of sex as consisting of non-penetrative practices that foster intimacy, arousal and, ultimately, satisfaction.  

Achieving sexual stimulation and satisfaction as an older person is an excellent goal and made easier than ever before by the number of potential partners available through online dating websites. However, the diagnoses of sexually transmitted infections such as chlamydia and gonorrhoea have increased by over 50% among Australian adults aged 60+ in the last 5 years, although very few older people report having been tested.  Given such a rise you could be forgiven for thinking that GPs and their older patients would be talking about sexual health, but you would be wrong.  They don’t.  Although such discussions with younger patients are considered by GPs to be a core preventive health activity, sexual health is seldom discussed between GPs and their older patients.  

Why don’t GPs talk about sexual health with older patients?

Research has shown that GPs often make assumptions that older patients have little interest in sexual activity, possibly exacerbated by the fact that they have little knowledge about the sexual health needs of their older patients themselves. Other research shows that while they might be embarrassed to actually start sexual health conversations with GPs, older people want to be asked and they want to have the opportunity to talk about sex. A recent article on The Conversation highlighted the Catch-22 situation of ‘Don’t Ask, Don’t Tell’ which exists between older people and their GPs about sexual health. 

Given the health and wellbeing effects of remaining sexually active as we age, we need to overcome this Catch-22.  The implications of the costs to the health care system from the rising incidence of sexually transmitted infections also need to be considered, particularly as there is evidence that older people in new relationships do not routinely use condoms. What’s more, there is little or no sexual health policy in Australia directly addressing the sexual health needs of older people.  Whilst no-one is endorsing routine screening of older people, these issues make it more challenging to advocate for their sexual health.

How do we break the impasse?

One method which is successful at increasing the rate of discussions between doctors and their patients about specific health conditions is the use of self-administered screening tools.  For example, when women completed a tablet-based breast cancer risk tool in their GPs' waiting room, there was a significant increase in GP discussions of the risks, lifestyle behaviours and referrals. And an interactive computer program completed during a consultation rather than in the waiting room, increased sexual health discussions between healthcare practitioners and young people in the UK.  Interestingly, a self-administered sexual-health-screening tool has never been developed or evaluated for use by older patients in the primary-care setting.  Such a tool may be just as effective at supporting sexual health discussions between GPs and their older patients as it is for younger ones, particularly given the increasing use of technology among older people.  Of course, we need to identify what format would be most acceptable to older patients.

A new Australian study has been funded to investigate this issue from the perspectives of healthcare practitioners as well as their older patients.  The results will, ultimately, be used to develop an interactive tool to facilitate such sexual health conversations occurring.  If both GPs and their older patient can feel comfortable in discussing sexual health rather than dancing around the issue, the results might lead to improved health outcomes for older patients.