Managing the rise in STIs among older adults

A new research review presented at a pre-congress day for this year's European Congress of Clinical Microbiology and Infectious Diseases (ECCMID 2024, Barcelona, 27-30 April) will look at how to manage the rise in sexually transmitted infections (STIs) in older people, such as gonorrhea, syphilis, and genital warts. It will focus on the importance of sex, intimacy, and sexual health to the Baby Boomer generation, especially given that 1 in 6 individuals worldwide will be aged 60 and older by 2030. The presentation will be given by Professor Justyna Kowalska from the Medical University of Warsaw, Hospital for Infectious Diseases in Warsaw, Poland-;who will highlight the need for conversations around older people and sexual health to be normalized.

Data from the US Centers for Disease Control and Prevention (CDC) indicate that rates of chlamydia, gonorrhea, and syphilis among US adults aged 55 and older have more than doubled over the past 10 years. For example, rates of gonorrhea among those aged 55 to 64 years rose from around 15 cases per 100,000 people in 2015 to 57 per 100,000 in 2019 [1]. In England, 31,902 new STIs were recorded in the over 45s in 2015, which rose to 37,692 in 2019 – an increase of 18%, with the majority of new diagnoses in men who have sex with men [2]. High STI prevalence estimates have also been reported more broadly in older adults around the world, including China, Korea, Kenya, and Botswana.

Rising divorce rates, forgoing condoms as there is no risk of pregnancy, the availability of drugs for sexual dysfunction, the large number of older adults living together in retirement communities, and the increased use of dating apps are likely to have contributed to the growing incidence of STIs in the over 50s. These data likely underestimate the true extent of the problem as limited access to sexual health services for the over 50s, and trying to avoid the stigma and embarrassment both on the part of older people and healthcare professionals, is leading to this age group not seeking help for STIs."

Professor Justyna Kowalska from the Medical University of Warsaw

Compounding the problem are the many misconceptions around sexuality and sexual activity in older adults, and the importance of sex and intimacy to older people's happiness and wellbeing. As Professor Kowalska explains, "People do not become asexual with age. In fact, with preventive medicine and improved lifestyles people are enjoying a healthy life and sex life for longer. Older people often find greater satisfaction in their sex lives due to experience and known expectations. We need more role models like Samantha Jones in the TV show Sex and the City to challenge stereotypes around older sexuality."

Although the frequency of sexual activity tends to decline with age, older adults are still having lots of sex. In a study in England, half of men and almost a third of women aged 70 and over reported being sexually active. Similarly, in a Swedish study, 46% of individuals aged 60 years and older reported being sexually active, as did 10% of those aged 90 years or older.

Studies show higher levels of sexual desire, greater sexual frequency, and more sexual partners among older men than women. A retrospective study from the USA involving 420,790 couples aged 67 to 99 years, found that widowhood was associated with an increased risk of STIs in older men, but not women. And the effects in men were larger after sildenafil (Viagra), the first phosphodiesterase type 5 inhibitor (PDE5 inhibitor), hit the market. Professor Kowalska says, "These findings indicate that sexual risk taking is common among older adults, particularly men. Given that the number of people aged 60 years and older is set to double worldwide by 2050 and the widespread availability of drugs to enhance sexual activity, health professionals must be proactive in discussing sexual concerns and making sexual health a routine part of general health care for older adults."

Although the incidence of STIs among the over 50s is small compared to younger age groups, it is rising, and Prof Kowalska will call for raising awareness about sexual health in older adults, explaining that they came of age at a time when sex education in school did not exist. "Sexual health campaigns are focused on young people and overlook the needs and experiences of those aged 50 and older", she says. "Health promotion messages give the impression that condoms and concerns about STIs only apply to young people. But the dangers of undiagnosed and untreated STIs such as HPV-related cancers and onwards transmission are very real, particularly in this age group who are more likely to have underlying conditions such as heart disease and stroke."

Prof Kowalska will also highlight the lack of evidence for using communication to promote positive behaviors to reduce the spread of STIs in older adults, particularly outside the USA and for infections other than HIV. "Increasing older adults' knowledge of the risk of STIs and how to engage in safer sex is crucial to tackling record levels of STIs", says Professor Kowalska. "Tailoring education programs to the over 50s and including peer support and ensuring they are located within existing community settings is vital to their success." Ultimately she says, "Older people have a right to good sexual health, so let's normalize conversations around sex and older people, and change the narrative on aging."